THE  OPTIC  NERVE 


AND 


HE  ACCESSORY  SINUSES 


OF  THE  NOSE 


PROFESSOR    A.  ONODI 


From 

PAUL  fa. 

•'EBER 

M'-dKi) 

KS 

69  F 

";.  Y. 

THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 
LOS  ANGELES 


^ 


THE  OPTIC  NERVE 

AND   THK 

ACCESSORY  SINUSES  OF  THE  NOSE 


THE  OPTIC  NERVE 

AND 

THE    ACCESSORY    SINUSES 
OF    THE    NOSE 

A  CONTRIBUTION  TO 

THE  STUDY  OF  CANALICULAR  NEURmS  AND 

ATROPHY  OF  THE  OPTIC  NERVE  OF  NASAL  ORIGIN 

BY 

PROFESSOR  A.    ÖNODI 

(UNIVERSITY,  BUDAPEST) 

MKMUEK   OK   Tilli   HUNGAKIAX   ACADEMY   OF  SCIENCES;    HOXORAKY    MEMHEK   OF   THE    AMERICAN 

I.AKY.\C;OLOGICAL,   RHINOLOGICAL   AND  OTOLOGICAL  SOCIETY.   AXD  OF  THE  ITALIAN 

SOCIETY  FOR  DISEASES  OF  THE  EAR,  NOSE  AXD  LARYNX,   ETC..  ETC. 

AUTHORIZED    TRANSLATION 

BY 

J.   LÜCKHOFF,   M.D.   Edin.,   Ch.B. 

CAPK    TOWN 

WITH   FIFTY   ILLUSTRATIONS 


NEW     YORK 

WILLIAM    W^OOD    cV    COMPANY 

MDCCCCX 


r 


7 


PREFACE    TO    THE    ENGLISH    EDITION 

The  German  edition  of  my  book  was  published  in  1906,  and  contained 
twenty-seven  illustrations  only.  While  personally  discussing  the 
English  translation  with  my  honoured  colleague,  Dr.  Liickhoff  of 
Cape  Town,  I  decided  to  make  considerable  additions  to  that  number, 
thus  rendering  the  work  more  complete  and  instructive.  Instead,  there- 
fore, of  only  twenty-seven  illustrations,  the  English  edition  contains 
fifty.  In  order  to  bring  it  quite  up  to  date,  I  have  also  made  use  of  the 
addresses  which  I  delivered  on  the  subject  at  the  First  International 
^Laryngological  Congress  held  in  Vienna  in  1908,  and  at  the  Annual 
:  Meeting  of  the  Academy  of  Ophthalmology,  Rhinology,  and  Oto-laryn- 
!  gology  in  New  York  in  1909.  It  is  my  pleasant  duty  on  this  occasion 
to  express  my  gratitude  to  Dr.  Liickhoff  for  the  care  he  has  devoted  to 
the  translation,  to  Dr.  Lamb  of  Birmingham  for  his  kind  assistance 
in  seeing  the  proofs  through  the  press,  and  to  the  publishers  for  the  hand- 
some appearance  they  have  given  to  my  book. 


A.  ONODI. 


Budapest, 

February,   19 10. 


PREFACE    TO    THE    GERMAN    EDITION 

The  minute  anatomy  of  the  nasal  accessory  sinuses  and  their  relations 
to  the  optic  nerves  have  now  engaged  my  attention  for  a  period  of 
ten  years.  The  results  I  have  obtained  provide  an  anatomical  basis 
for  the  study  of  visual  disturbances  and  blindness,  associated  with 
disease  of  the  accessory  sinuses,  and  especially  with  disease  of  the 
posterior  ethmoidal  cells  and  the  sphenoidal^  sinuses.  An  accurate 
study  of  the  pathological  anatomy  of  this  subject  is  still  required.  To 
this  and  to  accurate  clinical  observation  we  must  look  for  the  filling  up 
of  the  numerous  gaps  in  our  knowledge  of  this  subject.  To  my  honoured 
colleagues  I  pass  on  the  result  of  these  researches,  in  the  hope  that  it 
may  stimulate  others  to  pursue  this  important  subject  to  a  successful 
issue,  both  through  ophthalmic  and  rhinological  research. 

My  illustrations  have  been  reproduced  from  photographs,  natural 
size.  I  demonstrated  ten  of  the  specimens  at  the  Thirty-third 
Ophthalmological  Congress,  held  at  Heidelberg  in  1906.  Eight  speci- 
mens reproduced  in  my  atlas,  "  The  Accessory  Sinuses  of  the  Nose," 

I  have  again  utilized  in  this  treatise. 

A.  ONODI. 

Budapest. 


THE  OPTIC   NERVE 

AND   THE 

ACCESSORY    SINUSES    OF    THE   NOSE 


TOPOGRAPHICAL  ANATOMY 

Up  to  the  present,  the  more  intimate  relationships  of  the  optic,  nerves 
to  the  nasal  accessory  sinuses,  and  their  topographical  anatomy,  have 
not  been  thoroughly  worked  out.  In  textbooks  on  anatomy,  in  the 
description  of  the  course  of  the  optic  nerves  in  the  base  of  the  skull, 
their  association  with  the  accessory  sinuses  is  naturallv  pointed  out. 

In  their  monograph  on  the  relationship  of  the  optic  nerves  to  the 
sphenoidal  sinus,  Berger  and  Tyrman^  give  three  illustrations  which 
demonstrate  the  variation  in  the  thickness  of  the  sphenoidal  sinus 
walls  at  the  level  of  the  optic  foramen.  Further,  they  show  two 
skulls  "  in  which  the  ethmoidal  labyrinth  expanded  itself  posteriorly 
to  such  a  degree  that  the  anterior  sphenoidal  wall  lav  in  a  position 
posterior  to  the  optic  canals,  so  that  these  no  longer  bordered  on  the 
sphenoidal  sinus."  Zuckerkandl-  and  Douglas^  have  described  the 
sphenoidal  sinuses  in  their  relation  to  the  lesser  wings  of  the  sphenoid. 
Such,  covering  a  long  period  of  years,  are  the  antecedent  investigations. 

I  have  already  in  my  published  works  demonstrated  the  frequent 
and  intimate  relationship  of  the  optic  nerves  to  the  most  posterior 
ethmoidal  ceWj  and  have  for  this  reason  pointed  out  that  we  must 
relinquish  the  rigid  acceptation  of  the  relationship  of  the  optic  nerves 
to  the  sphenoidal  sinus. 

The  investigations  completed  by  me  up  to  the  present  have  estab- 
lished thirty-eight  variations  in  the  relationships  of  the  optic  nerves  to 
the  most  posterior  ethmoidal  cell,  and  the  sphenoidal  sinus.     When 

^   "  Diseases  of  the  Sphenoid  and  of  the  Ethmoitl  Labyrinth,"  iS86. 

-   "  Anatomy  of  the  Nasal  Cavities,"  188.2,  1893. 

^  Monatsschrift  für  Ohren-  und  Kehlkopfkrankheiten,  1897. 

I 


THE  OPTIC  XERVE 


we  consider  the  embryological  relationships  of  the  optic  sulcus  and 
optic  canal,  and  pay  attention  to  the  varieties  of  form  which  individual 
parts  of  the  sphenoid,  such  as  the  prc^esphenoid,,  orbito-sphenoid,  and 


I'M 

■_r_    tr,  -,'  T, 

,       ■    ■  ^  '^ 

-^       -*  "-.  C  ;:5 
<  o 


basi-sphenoid,  show  both  in  foetal  and  post-natal  periods,  then  such 
variations  become  intelligible.  And  when  we  more  carefully  con- 
sider the  development  of  the  sphenoidal  sinuses,  the  appearance  of 
the  muscles  attached  to  the  sphenoid,  and  the  development  of  the 


TOPOGRA  PH  IC  A  L  A  XA  TOM  Y 


ethmoidal  cells  and  frontal  sinus,  as  well  as  the  appearance  of  the 
ossification  centres,  which  already  in  fcetal  and  post-natal  periods 
produce  variations  in  shape  and  relationship,  then  we  can  explain 
the  large  number  of  varieties,  and  the  striking  peculiarities  which  T 
have  found,  and  which  I  will  discuss  later.     At  present  I  do  not  wish 

4 


Fig.  2. — Natural  Size. 


1.  Roof  of  orbit. 

2.  Middle  cranial  fossa. 

3.  Optic -feact,  ^  I 

4.  Optic  chiasma. 

5.  Optic  nerve.    •;    -^  ;>.f^.'. 


6.  Internal  carotid  artery. 

7.  Third  nerve — oculo-motor. 

8.  Fourth  nerve — trochlearis. 

9.  Fifth  nerve — trigeminus. 
lu.   Sixth  nerve — abducens. 


to  enter  upon  a  close  analysis  of  the  morphological  relationships.  It 
will  be  sufficient  to  define  the  topographical  relationships  of  the  optic 
nerves,  optic  canal,  and  optic  sulcus,  to  the  posterior  ethmoidal  cells 
and  the  sphenoidal  sinuses. 

The  thirty-eight  different  varieties  which  I  have  found  will  fall 

I — 2 


4  THE  OPTIC  XERVE 

into  twelve  main  groups.  These  I  will  describe  individually,  with 
the  aid  of  photographs  of  the  specimens,  which  are  reproduced  in 
natural  size.  In  order,  later,  to  have  a  clearer  view  of  the  varying 
relationships  of  the  optic  nerves,  optic  sulcus,  optic  foramina,  and  optic 
canals,  to  the  posterior  ethmoidal  cells  and  sphenoidal  sinuses,  I  will 
proceed  first  to  illustrate  the  position  of  these  in  the  base  of  the  skull. 
Figure  i  illustrates  on  a  bone  preparation  the  region  of  the  optic 
foramina  and  optic  sulci.     The  small  wing  of  the  sphenoid  or  ala 


Fig.   3. — Natural  Size. 

1.  Optic  nerve.  6.  Maxillary  antrum. 

2.  Sphenoidal  sinus.  7.   Frontal  lobe. 

3.  Internal  carotid  artery.  8.   Dura  mater. 

4.  Frontal  sinus.  9.   Nasal  cavity. 

5.  Orbital  recess  of  frontal  sinus.  xxxxxxxx,  Ethmoidal  cells. 

parva  bridges  the  sphenoidal  fissure  on  each  side,  and  medial  to 
this  is  the  optic  foramen,  which  prolongs  itself  into  a  short  optic 
canal.  The  roofs  of  the  optic  foramina  together  form  a  low  ridge, 
which  is  called  the  "  limbus  sphenoidalis,"  and  forms  the  boundary 
of  the  jugum  sphenoidale.  The  optic  sulcus  lies  between  these  and 
the  sella  turcica. 

Figure  2  illustrates  the  optic  nerve  as  it  enters  the  optic  foramen 
of  its  side,  and  also  the  chiasma  and  optic  tract.     The  flattened  bands 


TOPOGRAPHICAL  AX  ATOMY  5 

which  form  the  optic  tracts  unite  and  cross  in  the  chiasma,  which 
hes  in  the  sulcus,  between  the  sphenoidal  limbus  and  the  tuberculuni 
sellae.     From  the  chiasma  pass  the  optic  nerves,  to  extend  into  the 


Fig.  4. — Natural  Size. 


1.  Optic  chiasma. 

2.  Left  optic  nerve. 

3.  Right  optic  nerve. 

4.  Internal  carotid  artery. 

5.  Middle  cranial  fossa. 

6.  Anterior  cranial  fossa. 

7.  Right  sphenoidal  sinus. 

8.  Left  sphenoidal  sinus. 


9.  Left  ma.xillary  antrum. 

10.  Periosteum  of  orbit. 

1 1.  Right  frontal  sinus. 

1 2.  Left  frontal  sinus. 
1  3.  Nasal  cavity. 

14.  Olfactory  fissure. 

15.  Spheno-ethmoidal  recess — left. 

16.  Eyeball. 


X  X  X  X  X  X.  Etiimoidal  cells. 


optic  foramina,  above  the  ophthalmic  arteries.  The  illustration  further 
shows  the  internal  carotid  in  its  course  to  the  brain,  as  well  as  the 
trunks  of  the  oculo-motor,  trochlear,  trigeminal,  and  abducens  nerves. 


Fig.   5. — Natural  Size. 

Sphenoidal  sinus.  7.   Inferior  turbinal. 

Optic  nerve.  8.   Superior  meatus. 

Frontal  lobe.  9.   Palato. 

Frontal  sinus.  10.   Septum. 

Unciform  process.  11.  Naso-pharyngeal  cavity. 

Middle  turbinal.  12.   Eustachian  tube. 

X  X  X  X  X,  Ethmoidal  cells. 


TOPOGRAPHICAL  ANATOMY  7 

In  Figures  2  and  104  (Atlas) ^  the  optic  tract  is  shown  in  situ  in 
its  relationship  to  the  base  of  the  brain.  Figure  2,  in  sagittal  section, 
illustrates  the  position  of  the  optic  tract  in  its  relationship  to  the 
sphenoidal  sinus.  Figure  104  illustrates,  in  sagittal  section,  a  specimen 
which  had  been  injected  with  a  10  per  cent,  formalin  solution,  in 
order  to  retain  the  mucous  membrane  of  the  individual  sinuses  in 
its  saccular  form.  In  it  are  seen  in  situ  the  maxillary,  frontal, 
ethmoidal,  and  sphenoidal  sinuses,  as  well  as  the  optic  tract  in 
its  relationship  with  the  base  of  the  brain  and  with  the  sphenoidal 
sinuses. 

Figure  3  illustrates  a  formalin-hardened  specimen  with  the 
structures  that  lie  in  touch  with  the  walls  of  the  orbital  cavities 
exposed  to  view.  The  bone  of  these  walls  having  been  removed,  the 
mucous  membrane  of  the  accessory  sinuses  is  shown  in  its  natural 
shape,  as  well  as  the  under  surface  of  the  frontal  lobes  of  the  brain, 
and  the  optic  nerve  and  internal  carotid  artery.  The  position  of  the 
optic  nerve  and  its  intimate  relation  to  the  sphenoidal  sinus  is 
seen. 

Figure  4  illustrates  a  formalin-hardened  specimen.  In  it  can  be 
seen  the  position  of  the  optic  chiasma,  and  the  course  of  the  left  optic 
nerve  up  to  its  entry  into  the  eyeball.  This  nerve  touches  upon  the 
left  sphenoidal  sinus.  The  different  accessory  sinuses,  in  saccular 
form,  are  also  shown.  On  the  left  side,  in  addition,  appears  the  roof 
of  the  left  nasal  cavity,  and  on  the  right  the  sinuses  in  their  relation 
to  the  periosteum  of  the  orbit. 

Figure  5  illustrates  a  specimen  hardened  in  formalin,  in  which  the 
nasal  cavities  have  been  opened  from  without.  It  shows  in  sagittal 
section  the  accessory  sinuses,  and  the  optic  nerv^e  in  its  association  with 
the  posterior  ethmoidal  cells  and  sphenoidal  sinuses. 

In  those  cases  in  which  the  wall  of  the  optic  canal  is  formed  out  of 
the  wall  of  the  most  posterior  ethmoidal  cell,  the  partition  between  the 
canal  and  sinus  is  usually  thin,  and  may  in  some  cases  be  very  thin. 
In  one  case  it  measured  i  millimetre,  in  another  2  millimetres,  in 
thickness.  Iri^fiiose  cases  in  which  the  walls  of  the  optic  sulcus  and 
optic  canals  are  formed  by  the  wall  of  the  sphenoidal  sinuses  the 
variation  in  thickness  may  range  between  i,  2,  3,  4,  5,  9,  and  12  milli- 
metres. '  Later  I  will  discuss  more  in  detail  the  practical  importance 
of  these  facts,  and  o(  dehiscences  which  may  be  present  in  the  optic 
canal,  as  well  as  the  importance  which  may  attach  to  an  optic  canal, 

1  Onodi.  "  Accessory  Sinuses  of  the  Nose,"  by  Holder,  Vienna. 


8 


THE  OPTIC  XERVE 


the  course  of  which  hes  within  the  sphenoidal  sinus  and  posterior 
ethmoidal  cell.  The  length  of  the  optic  canal  may  reach  6,  8,  lo,  or 
12  millimetres. 

Group  1. 

I.  To  this  group  belong  those  cases  in  which  neither  the  most 
posterior  ethmoidal  cell  nor  the  sphenoidal  sinus  stands  in  close 
relationship  with  the  optic  canal  or  optic  sulcus. 


-■■^■e?-' 


X.        ■    — 


f 


Fig.  6. — Natural  Size. 

I.   Optic  nerve.  ::.   Sphenoidal  sinus. 

3.   Maxillary  antrum. 

Figure  77  (Atlas)  illustrates  a  specimen  in  frontal  section,  in  which 
the  right  sphenoidal  sinus  is  12  millimetres  long,  10  millimetres 
broad,  and  9  millimetres  high,  and  the  left  is  9  millimetres  long, 
10  millimetres  broad,  and  20  millimetres  high.  The  ostium  of  each 
sinus  is  ^millimetre  in  diameter,  and  the  layer  of  bone  intervening 
between  the  sphenoidal  sinuses  and  the  optic  nerves  and  chiasma  in 
the  optic  canals  and  sulcus  measures  from  8  to  12  millimetres  in 
thickness. 


TOPOGRAPHICAL  ANATOMY  9 

Figure  6  likewise  shows  a  specimen  in  frontal  section,  in  which 
bone  6  millimetres  in  thickness  separates  the  optic  nerve  from  the 
sphenoidal  sinus  and  the  ethmoidal  cell.  On  the  surface  of  the 
section  are  to  be  seen  the  optic  nerve,  sphenoidal  sinus,  and  maxillary 
antrum. 

Figure  76  (Atlas)  illustrates  a  frontal  section  at  the  level  of  the 
posterior  border  of  the  nasal  septum, (m  which  bone  8  millimetres  in 
thickness  separates  the  sphenoidal  sinus  from  the  hvpophysis.  Above 
this  lie  the  optic  tracts  and  optic  chiasma. 

Group  2. 

There  are  three  varieties  of  relationship  between  the  ethmoidal 
cells  and  the  optic  nerves,  which  I  class  under  this  group. 

2.  The  inner  and  lower  walls  of  the  optic  canal  may  be  formed 
out  of  the  wall  of  the  most  posterior  ethmoidal  cell. 

Il  Figure  7  illustrates  this  relationship.  Here  the  sphenoidal  sinuses 
/are  placed  beneath  the  posterior  etlimoidal  cells,  and  stand  in  no 
'relation  to  the  optic  nerves.  The  ostia  of  the  sphenoidal  sinuses 
open  below  the  level  of  the  floor  of  the  posterior  ethmoidal  cells. 

On  the  other  hand,  the  inner  and  lower  walls  of  tlie  optic  canal 
border  on  the  ethmoidal  cells,  this  relation  being  maintained  up  to 
the  level  of  the  optic  foramina. 

The  width  of  the  thin  partition  between  the  sphenoidal  sinuses 
and  ethmoidal  cells  is  20  millimetres  on  the  right  side,  and  15  milli- 
metres on  the  left  side.  The  anterior  walls  of  the  sphenoidal  sinuses 
are  extremely  small. 

3.  The  inner  wall  of  the  right  optic  canal  is  formed  by  the  wall 
of  the  right  posterior  ethmoidal  cell,  and  the  inner  and  lower  walls 
of  the  left  optic  canal,  and  also  the  left  third  of  the  optic  sulcus,  are 
formed  by  the  wall  of  the  left  posterior  ethmoidal  cell. 

4.  The  inner  and  lower  walls  of  the  right  optic  canal  and  the  wall 
of  the  middle  and  right  third  of  the  optic  sulcus  are  formed  by  the 
wall  of  a  large  ethmoidal  cell  on  the  right  side.  The  inner  wall  of  '  ' 
the  left  optic  canal  and  the  wall  of  the  left  third  of  the  optic  sulcus 
are  formed  by  the  wall  of^^  large  ethmoidal  cell  on  the  left  side, 
which  unites  with  the  frontal  sinus  of  that  side. '  "r»,\ 

Figure  8  illustrates  such  a  specimen  in  horizontal  section. 

This  is  a  structural  and  not  a  pathological  anomaly,  for  the  struc- 
tures everywhere  show  normal  relations,  and  the  openings  of  the 
sinuses  are  symmetrical  on  the  two  sides. 


10 


THE  OPTIC  XERVE 


On  the  left  side  the  ethmoidal  cells  have  not  only  coalesced  into 
one  cavity,  but  this  cavity  is  also  continuous  with  the  left  frontal 
sinus.  In  this  manner  is  formed  a  cavity  62  millimetres  in  length. 
The  frontal  sinus  itself  is  45  millimetres  broad  and  65  millimetres  in 
height.     Its  anterior  wall  is  7  millimetres  in  thickness. 

1  2 


Fig.   7. — Natural  Size. 


Right  optic  nerve. 

Left  optic  nerve. 

Posterior  ethmoidal  cell — right. 

Posterior  ethmoidal  cell — left. 

Ostium  of  sphenoid. 

Ethmoidal  cell. 

Superior  turbinal. 

15.   Septum. 


13- 


Middle  turbinal. 
Inferior  turbinal. 
Superior  meatus. 
Middle  meatus. 
Inferior  meatus. 
Maxillarv  antrum. 


14.   Hard  palate. 


On  the  right  side  the  ethmoidal  cells  coalesce  to  form  a  cavity 
45  millimetres  long.  It  is  separated  from  the  right  frontal  sinus.  It 
contains  two  recesses.  The  greatest  breadth  of  the  right  and  left 
ethmoidal  cavities  is  25  millimetres. 

The  right  frontal  sinus  is  23  millimetres  long,  40  millimetres  broad, 
and  40  millimetres  in  height.  This  cavity  has  a  recess.  Its  anterior 
wall  is  i^  millimetres  thick. 


TOPOGRA  PH  IC  A  L  A  XA  TOM  Y 


n 


On  the  right  side  a  sphenoidal  sinus  is  in  evidence. 

Distant  23  milUmetres  from  the  anterior  wall  of  the  frontal  sinus, 
on  each  side,  is  the  opening  of  the  anterior  ethmoidal  foramen.  This 
is  continued  downwards  in  the  lateral  wall  of  the  frontal  sinus  as  a 
groove  16  millimetres  in  length,  called  by  me  the  "  semicanalis  eth- 
moidalis."  On  each  side,  above  the  anterior  part  of  the  hiatus  semi- 
lunaris, the  frontal  sinus  opens  with  an  aperture  9  millimetres  long 
and  4  millimetres  broad. 

6 


/  i- 


// 


/ 


'>^7, 


.^  t 


e 


Fig.   8. — N.\tural  Size. 


1.  Left  ethmoidal  cavitv. 

2.  Right  ethmoidal  ca\-it\-. 

3.  Left  internal  carotid. 

4.  Right  internal  carotid. 


5.  Left  frontal  sinus. 

6.  Right  frontal  sinus. 

7.  Left  olfactory  fissure. 

8.  Right  olfactory  fissure. 


Into  the  posterior  end  of  the  hiatus  semilunaris  the  ma.xillary 
antrum  opens.  Both  the  unciform  process  and  the  ethmoidal  bulla 
are  well  defined. 

The  superior  turbinate  is  formed  by  a  ridge  passing  from  abo\-e 
the  middle  turbinate  bone,  and  in  tlie  groove  between  these  the 
ethmoidal  cells  open.  This  ostium  is  placed  symmetrically  on  the 
two  sides  in  the  superior  meatus. 


12 


THE  OPTIC  XERVE 


Group  3. 

In  this  group  the  most  posterior  ethmoidal  cell  is  in  relation 
to  the  optic  nerve.  There  are  seven  varieties  to  be  distinguished. 
In  aU  of  these  the  cell  is  in  relation  to  the  nerve  of  the  same  side,  but 
in  two  it  is  in  relation  also  with  the  optic  nerve  of  the  opposite  side. 


Fig.  g. — Xatlral  Size. 


1.  Posterior  ethmoidal  cell. 

2.  Optic  nerve. 


;.  Septum. 


3.  Internal  carotid  artery. 

4.  Sphenoidal  sinus. 


5.  The  inner,  lower,  and  outer  walls  of  the  right  optic  canal,  and 
the  right  third  of  the  optic  sulcus,  are  formed  b}-  the  wall  of  the  pos- 
terior ethmoidal  cell  of  that  side. 

Figure  17  (Atlas)  shows  this  arrangement,  in  sagittal  section. 
The  large  sphenoidal  sinus  is  here  in  no  relation  to  the  optic  sulcus, 


TOPOGRAPHICAL  ANATOMY  13 

canal,  or  foramen.  It  is  22  millimetres  in  length  and  18  millimetres 
high.  The  most  posterior  ethmoidal  cell  is  30  millimetres  long,  and 
from  the  middle  line  18  millimetres  in  breadth.  This  cavity  passes 
under  the  optic  sulcus  and  the  optic  foramen  into  the  lesser  wing  of 
the  sphenoid.  It  forms  the  whole  wall  of  the  sulcus  and  the  inner, 
lower,  and  outer  walls  of  the  optic  canal  of  that  side. 


Fig.    10. — Xatur.vl  Size. 


1.  Optic  nerve. 

2.  Posterior  ethmoidal  cell. 

3.  Internal  carotid  artery. 

4.  Sphenoidal  sinus. 

5.  Optic  canal. 


6.  Superior  turbinal. 

7.  Middle  turbinal. 

8.  Inferior  meatus. 

9.  Middle  meatus. 
10.   Superior  meatus. 


6.  The  inner  and  lower  walls  of  the  left  optic  canal  and  the  whole 
of  the  optic  sulcus  are  formed  by  the  most  posterior  ethmoidal  cell  ot 
that  side. 

Figure  16  (Atlas)  illustrates  this  on  a  bone  specimen,  in  sagittal 
section.     The  posterior  ethmoidal  cell  is  11  millimetres  long,  14  milli- 


14 


THE  OPTIC  NERVE 


metres  broad  from  the  middle  line,  and  13  millimetres  high.  The 
relation  of  the  optic  canal  and  sulcus  is  as  above.  The  sphenoidal 
sinus,  though  large,  is  not  associated  with  the  optic  canal  or  optic 
sulcus.  Its  measurements  are  25  millimetres  long,  15  millimetres 
high,  and  from  the  middle  line  15  millimetres  broad. 

7.  The  inner  and  lower  walls  of  the  optic  canal  are  formed  by  tlie 
wall  of  the  most  posterior  ethmoidal  cell  of  the  same  side. 

Figure  13  (Atlas)  demonstrates,  in  sagittal  section,  a  posterior 
ethmoidal  cell  on  the  left  side,  which  for  6  millimetres  stretches  back 


Fig.    II. — Natural  Size. 

1.  Optic  canal.  4.   Internal  carotid  artery. 

2.  Optic  nerve.  5.   Sphenoidal  sinus. 

3.  Posterior  ethmoidal  cell.  6.   Frontal  sinus. 

7.   Ethmoidal  cells. 


underneath  the  optic  canal.  The  length  of  this  cell  is  34  millimetres, 
and  its  height  is  16  millimetres.  The  relations  of  the  optic  nerve 
are  shown.  The  accessory  sinuses  and  the  nasal  cavity  have  in  this 
specimen  been  exposed  to  view  from  without. 

8.  The  upper,  inner,  and  lower  walls  of  the  optic  canal  are  formed 
by  the  most  posterior  ethmoidal  cell. 

Figures  9  and  10  demonstrate  this  relationship.  In  Figure  9,  in 
sagittal  section,  it  is  seen  that  the  optic  canal  is  surrounded  on  the 
inner  side  from  roof  to  floor  by  the   posterior  ethmoidal    cell.      In 


i^'  K^ 


TOPOGRAPHICAL  ANATOMY 


Figure  10  is  represented  a  specimen,  in  frontal  section,  in  which  the 
accessory  sinuses  have  been  opened  from  the  front  and  from  the  nasal 
cavity.  On  the  right  side  is  seen  the  optic  canal,  lying  for  12  milli- 
metres of  its  course  in  the  outer  wall  of  the  right  posterior  ethmoidal 
cell.  The  cell  extends  from  above  the  canal  round  U)  its  inner 
and  lower  side.  The  optic  nerve  on  the  right  lies  beside  the  internal 
carotid  arterv.  and  is  sliown  in  its  course  up  to  the  optic  foramen. 


Fig.   i; 

1.  Optic  nerve. 

2.  Posterior  ethmoitlal  cell. 


-Natural  m/i 


Alveolar  cyst. 


3.  Sphenoidal  sinus. 

4.  ^Iaxillary  antrum. 


Figure  11  demonstrates,  in  sagittal  section,  (im  optic  (anal  on  the 
right  side,  of  10  millimetres  length,  which  has  its  course  in  a  right 
posterior  ethmoidal  celu  This  cell  is  15  millimetres  long  and  18 
millimetres  high.  The  optic  nerve  at  its  entrance  and  exit  can  be 
seen.     This  specimen  illustrates  the  fifth  variety  of  this  group. 

9.  In  it  the  optic  canal  is  almost  completely  surrounded  by  the 
posterior  ethmoidal  cell  as  it  lies  on  the  outer  wall  of  the  cell. 

The  cavity  lies  on  its  upper,  inner,  and  lower  walls  and  on  part  of 
its  outer  wall  {vide  Figure  10) . 


i6 


THE  OPTIC  XERVE 


10.  The  inner  wall  of  the  optic  canal  lies  against  the  posterior 
ethmoidal  cell  of  that  side. 

Figure  12  illustrates  this  relationship  in  sagittal  section,  on  the 
left  side.  The  nerve  is  shown  at  its  entry  into  the  optic  canal.  The 
canal  runs  in  the  outer  wall  of  the  cell  for  a  distance  of  6  millimetres, 
and  to  demonstrate  this  the  wall  of  the  canal  has  been  opened  up. 

11.  The  floor  of  the  optic  canal  is  formed  on  the  one  side  by  the 
roof  of  the  posterior  ethmoidal  cell. 


Fig.    13. — Xatlral  Size. 


1.  Optic  nerve. 

2.  Internal  carotid  arterv. 

3.  Posterior  ethmoidal  cell. 

4.  Sphenoidal  sinus. 


Superior  turbinal. 
Middle  turbinal. 
Inferior  turbinal. 
Frontal  sinus. 


Figures  13  and  14  illustrate  this.  Figure  13  illustrates,  in  sagittal 
section,  the  course  of  the  left  optic  nerve  for  a  distance  of.  7  milli- 
metres, as  it  passes  above  the  posterior  ethmoidal  cell.  Its  bony 
covering  has  been  removed. 

12.  On  both  sides  the  inner  and  lower  walls  of  the  optic  canals, 
as  well  as  the  whole  optic  sulcus,  are  formed  bv  the  walls  of  the 
posterior  ethmoidal  cells. 

In  Figure  14  (Atlas)  this  relationship  is  shown,  and  also  in  a  corre- 


TOPOGRA  PH  IC  A  L  A  NA  TOM  Y 


17 


spondirrg  sagittal  section.  Figure  15  illustrates  this.  The  posterior 
ethmoidal  cell  in  this  specimen  measures  22  millimetres  in  length, 
38  millimetres  in  breadth,  and  17  millimetres  in  height,  on  the  right 
side.  This  cavity  has  expanded  itself  so  as  to  extend  over  the  sphe- 
noidal sinuses,  and  lies  thus  in  relation  to  both  optic  nerves  and  to 


Fig.    14. — Natural  Size. 

I. 

2 

3- 
4- 

5- 

Optic  nerve.                                             6.   Superior  turbinal. 
Posterior  ethmoidal  cell.                        7.  Middle  turbinal. 
Anterior  cranial  fossa.                             8.   Inferior  turbinal. 
Ethmoidal  cell.                                         y.  ^laxillary  antrum. 
Sphenoidal^sinus.                                    10.   Alveolar  cyst. 

the  chiasma.     The  floor  of  the  optic  canals  and  the  whole  optic  sulcus^  |^       /  S 
in  this  manner  are  formed  by  a  thin  plate  of  bone,  which  separates  it        ^,  T 
from  the  sinus. 

13.  The  inner  wall  of  the  right  optic  canal  is  formed  by  the  left 
posterior  ethmoidal  cell. 


i8 


THE  OPTIC  XERVE 


Figure  53  (Atlas)  illustrates  this  in  sagittal  section.  The  sphe- 
noidal sinuses  are  so  asymmetrically  placed  that  the  left  sphenoidal 
sinus  lies  in  front  of  the  right.     The  right  sinus  is  18  millimetres  long, 


Fig.    i;. — Natural  Size. 


1.  Left  optic  nerve. 

2.  Posterior  ethmoidal  cell. 

3.  Left  sphenoidal  sinus. 

4.  Left  frontal  sinus. 

5.  Superior  turbinal. 

6.  Middle  turbinal. 


7.  Ostium  of  maxillary  antrum. 

8.  Superior  meatus. 

9.  Middle  meatus. 

10.  Inferior  turbinal. 

1 1.  Inferior  meatus. 

12.  Palate. 


15  millimetres  broad,  and  16  millimetres  high  ;  the  left  is  15  milli- 
metres long,  16  millimetres  broad,  and  17  millimetres  high.  The  left 
posterior  ethmoidal  cell  is  16  millimetres  long  and  15  millimetres 
broad. 


,  Right  optic  nerve. 

,  Right  sphenoidal  s 
.  Left  sphenoidal  sir 


Riglit  frontal  sinus. 

15,   Fifth  nerve — trigeminal. 

Olfactory  fissure. 

1(1.  Sixth  nerve — abducens, 

17.   Facial  and  auditory  nerves. 

Middle  cranial  fossa. 

IS.  Glosso-pliaryngeal  nerve,  va 

Posterior  cranial  fossa. 

Third  nerve— ociilo-motor 

19.  Hypoglossal  nerve. 

Fourth  nerve — trochlear. 

xxxxxxxxx.  Flhmoid 

r 


TOPOGRA  PH  IC  A  L  A  NA  TOM  Y 


23 


Group  4. 

Oll  both  sides  the  optic  ner\'es  stand  in  close  rehition  to  the 
sphenoidal  sinuses.     There  are  five  varieties. 

14.  On  both  sides  the  inner  and  lower  walls  of  the  optic  canals 
and  the  wall  of  the  optic  sulcus  are  formed  by  the  sphenoidal  sinuses. 
In   Figure    16,   which   illustrates   a  specimen   hardened   in   formalin, 


G     K^  #-     -^ 


11 


12  13 


10 


Fig.    17. — Natural  Size. 


1.  Optic  nerve. 

2.  Right  sphenoidal  sinus. 

3.  Left  sphenoidal  sinus. 

4.  Sphenoidal  ostium. 

5.  Superior  turbinal. 

6.  Superior  meatus. 


13.   Palate. 


7.  Middle  turbinal. 

8.  Middle  meatus. 

9.  Maxillary  antrum. 

10.  Inferior  turbinal. 

11.  Inferior  meatus. 

12.  Septum. 


it  can  be  seen  that  the  upper  walls  of  the  accessory  sinuses  ha\'e  been 
removed  through  the  anterior  and  middle  cranial  fossae.  The  mucous 
membranes,  in  their  original  saccular  form,  are  seen  seriatim  from 
before  backward.  They  are  the  lining  membranes  of  the  frontal, 
ethmoidal,  and  sphenoidal  sinuses.  The  right  sphenoidal  sinus 
lies  in  front  of  the  left,  and  the  left  stretches  back  behind  the 
right. 

2 — 2 


24 


THE  OPTIC  XERVE 


15.  On  both  sides  the  inner  walls  of  the  optic  canal  and  the  wall 
of  the  corresponding  third  of  the  optic  sulcus  are  formed  by  the 
sphenoidal  sinuses. 

Figure  75  (Atlas)  illustrates  in  frontal  section  the  sphenoidal  sinuses, 
with  the  optic  nerves  above  them,  as  they  enter  the  optic  canals. 


1.  Anterior  ethmoidal  cell. 

2.  Posterior  ethmoidal  cell. 

3.  Superior  turbinal. 

4.  Posterior  ethmoidal  cell — left. 

5.  Right  sphenoidal  sinus. 


6.  Left  sphenoidal  sinus. 

7.  Septum. 

8.  Middle  turbinal. 

9.  Palate. 

10.   Inferior  turbinal. 


Figure  17  illus crates  the  same  relationship.  The  sphenoidal 
sinuses  in  this  are  17  millimetres  broad.  28  millimetres  long,  and 
22  millimetres  high  on  the  right,  and  on  the  left  17  millimetres  broad, 
25  millimetres  long,  and  22  millimetres  high. 

Figure  18  shows  the  accessory  sinuses  and  nasal  passages  in  sagittal 
section.     The  sphenoidal  sinuses  are  as\-mmetrical,  the  left  sinus  (6) 


TOPOGRA  PH  IC  A  L  A  NA  TOM  Y 


25 


lying  in  front  of  the  right  (5).  The  right  sinus  is  18  millimetres  long, 
15  millimetres  broad,  and  16  millimetres  high ;  the  left  sinus  is 
15  millimetres  long,  16  millimetres  broad,  and  17  millimetres  high. 
I  Immediately  above  the  right  sphenoidal  sinus  is  the  most  posterior 
ethmoidal  cell ;  it  is  16  millimetres  long,  15  millimetres  broad,  and 
15  millimetres  high. 

Figure  19  shows  in  frontal  section  the  optic  nerves  in  this  relation 
to  the  lateral  walls  of  the  sphenoidal  sinuses. 

16.  On  each  side  the  inferior  wall  of  the  optic  canal  and  the  wall 
of  the  optic  sulcus  are  formed  by  the  sphenoidal  sinus.     Figure  19 


1.  Right  optic  nerve. 

2.  Left  optic  nerve. 

3.  Riglit  splienoidal  sinus. 


Fig.    ig. — Natural  Size. 

4.  Left  sphenoidal  sinus. 

5.  Middle  turbinal. 

6.  IMicklle  meatus. 


7.  Inferior  turbinah 

8.  Inferior  meatus. 

9.  Septum. 


illustrates  this  relationship.  The  left  sphenoidal  sinus  shows,  how- 
ever, a  greater  expansion,  and  forms  the  floor  of  the  optic  canal  as 
well  as  both  the  middle  and  left  tliird  of  the  optic  sulcus. 

17.  The  wall  of  the  optic  sulcus  on  both  sides  is  formed  by  the 
sphenoidal  sinuses. 

18.  On  the  right  side  the  inner  wall  of  the  optic  canal  and  the  optic 
sulcus  are  formed  by  the  sphenoidal  sinus  on  that  side,  and  on  the 
left  side  the  inferior  wall  of  the  optic  canal  is  formed  by  the  left 
sphenoidal  sinus. 

Figure  20  shows  in  a  vertical  transverse  section  the  close  relation  of 
tlie  optic  nerves  to  the  sphenoidal  sinuses  on  both  sides. 


26 


THE  OPTIC  XERVE 


Fig.  20. — Natural  Size. 


1.  Left  optic  nerve. 

2.  Right  optic  nerve. 

3.  Left  sphenoidal  sinus. 

4.  Right  sphenoidal  sinus. 

5.  Septum. 

6.  Left  temporal  lobe. 


7.  Right  temporal  lobe. 

8.  Left  frontal  lobe. 

9.  Right  frontal  lobe. 

10.  Dura  mater. 

1 1.  Falx  cerebri. 

12.  Superior  longitudinal  sinus. 


TOPOGRA  PH  IC  A  L  A  XA  TOM  Y 


27 


Group  5. 

The  optic  nerves  in  this  class  show  seven  varieties  of  relationship 
to  the  sphenoidal  sinuses,  four  of  which  are  to  the  sinus  of  the  same 
side,  two  to  that  of  the  opposite  side,  and  in  one  the  sinus  lies  in  the 
middle  line. 

19.  The  lower  wall  of  the  optic  canal  on  the  left  side  is  formed 
by  the  wall  of  the  left  sphenoidal  sinus,  and  also  tlie  whole  optic 
sulcus  is  formed  by  the  left  sphenoidal  sinus. 


Fig.   21. — Xatur.\l  Size. 


1.  Optic  nerve. 

2.  Sphenoidal  sinus. 

3.  Posterior  ethmoidal  cell. 

4.  Middle  turbinal. 

5.  Unciform  process. 


6.  Fontanelies  of  the  antrum,  where 

the  bony  wall  is  defective. 

7.  Ostium  of  maxillary  antrum. 

8.  Ethmoidal  bulla. 

9.  Frontal  sinus. 


10.   Inferior  turbinal. 

20.  The  left  sphenoidal  sinus  forms  the  floor  of  the  left  optic 
canal  and  the  wall  of  the  left  third  of  the  optic  sulcus.  A  similar 
relationship  may  occur  on  the  right  side. 

21.  The  sphenoidal  sinus  on  the  right  side  forms  the  inferior  wall 
of  the  right  optic  canal.  Figure  21  illustrates  a  formalin-hardened 
specimen,  in  which  the  bone  walls  of  the  right  orbital  cavity  have 


28 


THE  OPTIC  NERVE 


been  removed,  and  also  those  of  the  ethmoidal  cells,  that  are  in 
relation  to  the  optic  nerve.  This  relation  of  the  optic  nerve  to  the 
sphenoidal  sinuses  and  ethmoidal  cells  is  here  well  illustrated. 

Figure  4,  also  a  formalin-hardened  specimen,  shows  the  intimate 
relation  between  the  left  optic  nexxe  and  the  left  sphenoidal  sinus. 


Fig.  22. — Natural  Size. 

1.  Left  optic  nerve.  5.   Left  internal  carotid  artery. 

2.  Right  optic  nerve.  6.   Orbit. 

3.  Right  sphenoidal  sinus.  7.   Supra-orbital  nerve. 

4.  Right  internal  carotid  artery.  8.   Left  frontal  sinus. 

9.   Right  frontal  sinus. 

This  sinus  is  here  12  millimetres  long,  and  is  separated  from  the  floor 
of  the  optic  canal  only  by  a  very  thin  plate  of  bone.  Both  the  chiasma 
and  the  right  optic  nerve  are  separated  from  the  sinus  by  thick, 
spongy  bone. 

22.  The  right  sphenoidal  sinus  forms  the  medial  wall  of  the  right 


TOPOGRA  PH  IC  A  L  A  NA  TOM  Y 


29 


optic  canal.  This  is  shown  in  Figure  21,  in  sagittal  section.  The  thin 
septum  between  the  optic  canal  and  the  sphenoidal  sinus  has  been 
removed,  and  the  course  of  the  optic  nerve,  5  millimetres  long,  can  be 
seen  on  the  side-wall  of  the  sinus. 

23.  The  medial  wall  and  floor  of  both  optic  canals  and  the  whole 
wall  of  the  optic  sulcus  are  formed  by  the  right  sphenoidal  sinus. 
Figures  22  and  23  demonstrate  this. 


Fig. 
I  and  2.  Splienoidal  sinuses. 


-Natural  Size. 

3,  3.    Posterior  ethmoidal  cell. 


Figure  22,  a  formalin-hardened  specimen,  shows  from  abo\-e  the 
intimate  relations  of  the  right  sphenoidal  sinus  to  both  optic 
nerves,  while  Figure  23  shows  the  exceptionally  marked  asymmetry 
between  the  two  sphenoidal  sinuses,  the  left  one  being  of  small  size, 
and  pushed  quite  laterally. 

24.  The  right  sphenoidal  sinus,  as  is  seen  in  Figure  24.  is  in  intimate 


Fig.  24. — Xatural  Size 


1.  Left'optic  nerve. 

2.  Right  sphenoidal  sinus. 

3.  Right  optic  nerve. 

4.  Left  sphenoidal  sinus. 


5.  Middle  cranial  fossa.       .  /»     yl  ^ 

6.  Sphenoidal  ostium, 

7.  Inferior  turbinal — posterior  end. 
S.  Septum — posterior  edge. 


■/ 


Fig.   2;. — Natural  Size. 


1.  Optic  nerve. 

2.  Ethmoidal  cell. 

3.  Left  sphenoidal  sinus. 

4.  Superior  turbinal. 


5.  Middle  turbinal. 

6.  Inferior  turbinal. 

7.  Septum. 

8.  Maxillarv  antrum. 


o 


Optic  nerve. 
Optic  canal. 
Sphenoidal  sinus. 
Anterior  ctlimoidal  tell. 
Ethmoidal  bulla. 
Left  frontal  sinus. 
Right  frontal  sinus. 


Internal  c 


Inferior  meatus. 
Left  frontal  lobe. 
Superior  longittidiu 


4.  Genu  of  corpus  callosum. 

5.  Caudate  nucleus, 

6.  Lateral  ventricle. 

S.  Choroid  plexus. 

9.  Splenium  of  corpus  callosi 

20.  Falciform  process, 

21.  Occipital  lobe. 

22.  Straight  giuus. 

23.  Cerebellum. 

24.  Optic  thalamus. 

25.  Pons. 


TOPOGRAPHICAL  ANATOMY 


35 


2  — 


Fig.   27. — Natural  Size. 


1.  Left  optic  canal. 

2.  Left  sphenoidal  sinus. 

3.  Right  posterior  ethmoidal  cell. 

4.  Right  sphenoidal  sinus. 


5.  ]\Iiddle  cranial  fossa. 

6.  Internal  carotid  artery. 

7.  Posterior  cranial  fossa. 

8.  Clivus. 


Fig.  28. — Natural  Size. 


Right  sphenoidal  sinus. 
Right  optic  canal. 
Posterior  ethmoidal  cell. 
Left  sphenoidal  sinus. 


5.  Middle  cranial  fossa. 

6.  Posterior  cranial  fossa. 

7.  Clivus. 

8.  Internal  carotid  artery. 


36 


THE  OPTIC  NERVE 
16  17 


Fig.  29. — Natural  Size. 


1.  Left  optic  nerve. 

2.  Right  optic  nerve. 

3.  Left  sphenoidal  sinus. 

4.  Right  sphenoidal  sinus. 

5.  Right  posterior  ethmoidal  cell. 

6.  Septum. 

7.  Right  inferior  turbinal — posterior  end. 

8.  Left  inferior  turbinal — posterior  end. 


9.  Left  middle  turbinal — posterior>nd. 

10.  Left  temporal  lobe. 

11.  Right  temporal  lobe. 

12.  Left  lateral  ventricle. 

13.  Right  lateral  ventricle. 

14.  Left  frontal  lobe. 

15.  Right  frontal  lobe. 

16.  Dura  mater. 


17.   Falciform  process. 


TOPOGRAPHICAL  ANATOMY 


57 


Fig.    30. — Natural  Size. 


1.  Optic  nerve. 

2.  Sphenoidal  sinus. 

3.  Internal  carotid  artery. 

4.  Posterior  ethmoidal  cell. 

5.  Anterior  ethmoidal  cell. 

6.  Frontal  sinus. 

7.  Naso-frontal  duct. 

8.  Middle  turbinal. 


17- 


q. 

Bone-cell  of  the 

middle 

turbinal 

10. 

Middle  meatus. 

1 1. 

Inferior  turbinal 

12. 

Inferior  meatus. 
Septum. 

14- 

Palate. 

I  V 

Frontal  lobe.] 

16. 

Dura  mater. 

Arachnoid. 

38  THE  OPTIC  NERVE 

relation  to  the  left  optic  nerve,  and  is  separated  from  it  by  a  very 
thin  plate  of  bone. 

25.  The  left  sphenoidal  sinus  forms  the  middle  third  of  the  optic 
sulcus.  In  Figure  25,  represented  in  frontal  section,  this  can  be  seen. 
Here  the  left  sphenoidal  sinus  lies  in  the  middle  line,  above  the 
nasal  septum. 

,  The   sagittal   section  represented   in   Figure   26   shows   in   a  very 

instructive  way  the  intracranial  course  of  the  optic  nerve  from  the  optic 
thalamus  to  the  optic  foramen.  It  also  shows  the  entrance  of  the  optic 
nerve  into  the  optic  canal,  which  runs  for  a  distance  of  10  millimetres 
free  in  the  sphenoidal  sinus. 

Figures  27  and  28  show  in  horizontal  section  the  optic  canal, 
10  millimetres  long,  running  free  in  the  sphenoidal  sinus. 

Figure  29  represents  a  vertical  transverse  section  illustrating  the 
close  relation  of  the  right  optic  nerve  to  the  right  sphenoidal  sinus, 
and  also  that  of  the  left  optic  nerve  to  the  most  posterior  ethmoidal 
cell.  This  most  posterior  cell  on  the  left  side  is  situated  above  the 
sphenoidal  sinus. 

Figure  30  shows  a  sagittal  section  illustrating  the  close  relation  of 
the  optic  nerves  and  the  internal  carotid  arter}^  to  the  sphenoidal  sinus. 
The  sphenoidal  sinus  forms  the  thin  lower  wall  of  the  optic  canal. 

^'\v\^^^,-^  Group  6. 

Q|v/^  The  most  posterior  ethmoidal  cell  and  the  sphenoidal  sinus  are  in 
intimate  relation  with  the  optic  nerve  of  the  same  side.  There  are 
two  varieties. 

26.  The  left  posterior  ethmoidal  cell  forms  the  medial  wall,  and  the 
left  sphenoidal  sinus  the  inferior  wall,  of  the  left  optic  canal.  Figure  5, 
a  formalin-hardened  specimen,  illustrates  this. 

The  nasal  cavities  are  opened  from  without.  The  most  posterior 
ethmoidal  cell,  marked  with  a  X,  and  the  sphenoidal  sinus  in  rela- 
tion to  the  optic  nerve  are  seen. 

27.  The  left  most  posterior  ethmoidal  cell  forms  the  medial  wall  of 
the  left  optic  canal,  and  the  left  sphenoidal  sinus  forms  the  floor  of  the 
right  optic  canal  and  the  wall  of  the  right  and  middle  third  of  the  optic 
sulcus.  Figure  31,  a  formalin-hardened  specimen,  illustrates  this. 
In  it  the  inner  wall  of  the  orbital  cavity  has  been  removed,  and 
the  mucous  membrane  of  the  accessory  sinuses  is  shown  in  saccular 
form. 


TOPOGRAPHICAL  AX  ATOMY 


39 


The   most  posterior  ethmoidal  cell  on  the  left  side,  marked  with 
a   X,    in   relation   to   the  left  optic   nerve,   and   the  left  sphenoidal 


[^  k^F^M^ 


Fig.   31. — Natural  Size. 


1.  Left  optic  nerv'e. 

2.  Right  optic  nerve. 

3.  Internal  carotid  artery. 

4.  Middle  cranial  fossa. 

5.  Anterior  cranial  fossa. 

6.  Sphenoidal  sinus — left. 

7.  Eyeball. 


8.  Lachrymal  sac. 

9.  I-'rontal  sinus. 

10.  Falciform  process. 

11.  Maxillary  sinus. 

X  X  X  X  X  X.  Ethmoidal 
and  posterior. 


cells — anterior 


sinus  in  its  relation  to  the  right  optic  nerve,  are  shown.  The  same 
relationship,  in  the  absence  of  the  left  sphenoidal  sinus,  may  occur 
on  the  right  side. 


40 


THE  OPTIC  XERVE 


Group  7. 

The  posterior  ethmoidal  cells  and  the  sphenoidal  sinuses  show  a 
similar  relationship  on  both  sides  to  the  optic  nerves. 

28.  The  most  posterior  ethmoidal  cells  form  on  both  sides  the 
medial  wall  of  the  optic  canal  and  the  sphenoidal  sinuses  form 
the  wall  of  the  optic  sulcus. 


Group  8. 

The  most  posterior  ethmoidal  cells  on  both  sides  and  the  sphenoidal 
sinus  of  one  side  are  in  relation  to  the  optic  nerves.  There  are  two 
varieties. 

29.  The  right  posterior  cell  forms  the  floor  and  medial  wall 
of  the  right  optic  canal,  and  the  wall  of  the  right  third  of  the  optic 
sulcus.  The  left  posterior  ethmoidal  cell  forms  the  middle  wall  and 
the  floor  of  the  left  optic  canal,  and  the  wall  of  the  left  third  of  the 
optic  sulcus.  The  right  sphenoidal  sinus  forms  the  wall  of  the  middle 
third  of  the  optic  sulcus. 

Figure  67  (Atlas)  illustrates  this  relation,  in  frontal  section. 
The  right  sphenoidal  sinus  here  is  seen  to  lie  above  the  nasal  septum. 
This  prolongation  of  the  sphenoidal  sinus  extends  from  the  ostium 
sphenoidale,  15  millimetres  forwards,  and  comes  into  relation  with 
the  middle  third  of  the  optic  sulcus  and  with  the  chiasma. 

30.  The  left  sphenoidal  sinus  forms  the  wall  of  the  left  third  of 
the  optic  sulcus.  The  left  posterior  ethmoidal  cell  forms  the  middle 
wall  and  the  floor  of  the  optic  canal.  The  right  posterior  ethmoidal 
cell  forms  the  middle  wall,  roof,  outer  wall,  and  floor,  of  the  right  optic 
canal,  and  also  the  wall  of  the  right  third  of  the  optic  sulcus. 


Group  9. 

The  sphenoidal  sinuses  of  both  sides  and  the  posterior  ethmoidal 
cells  of  the  one  side  are  in  relation  to  the  optic  nerves. 

31.  The  left  sphenoidal  sinus  forms  the  middle  wall  of  the  left 
optic  canal,  and  the  right  sphenoidal  sinus  forms  the  middle  wall  of 
I  the  right  optic  canal.  The  right  posterior  ethmoidal  cell  fonns  the 
I  roof  of  the  right  optic  canal. 


TOPOGRAPHICAL  AX  ATOMY 


41 


Group  10. 

There  are  four  varieties  of  relationship  between  the  optic  nerve  and 
the  sphenoidal  sinus  of  the  one  side,  and  tiie  nerve  and  the  posterior 
ethmoidal  cells  of  the  other  side. 

32.  The  left  sphenoidal  sinus  forms  the  middle  wall  and  floor  of 
the  left  optic  canal,  and  the  whole  optic  sulcus  ;  it  also  forms  to  a 


14     1; 


Fig.   ^2. — Natural  Size. 


1.  Left  optic  nerve. 

2.  Right  optic  nerve. 

3.  Optic  canal. 

4.  Left  posterior  ethmoidal  cell. 

5.  Right  sphenoidal  sinus. 

6.  Left  sphenoidal  sinus. 

7.  Superior  turbinal. 


Palate 


8.  Superior  meatus. 

9.  Middle  turbinal. 

10.  Middle  meatus. 

11.  Inferior  turbinal. 

12.  Maxillary  antruni. 

13.  Inferior  meatus. 

14.  Septum. 


small  degree  the  floor  and  middle  wall  of  the  right  optic  canal,  though 
these  are  chiefly  formed  by  the  right  posterior  ethmoidal  cell. 

33.  The  left  most  posterior  ethmoidal  cell  forms  the  middle 
wall,  roof,  outer  wall  and  floor,  of  the  left  optic  canal  ;  the  right 
sphenoidal  sinus  forms  the  middle  wall,  roof,  outer  wall,  and  floor  of 
the  right  optic  canal.  In  Figure  32  and  in  my  Atlas  in  Figure  72. 
which  illustrates  a  corresponding  frontal  section,  this  relation  is  shown. 

■5 


42  THE  OPTIC  XERVE 

\ "  "^C  Both  figures  demonstrate  in  an  instructive  manner  the  relation  of  the 

optic  ner\'e  and  optic  canal  on  the  one  side  to  the  sphenoidal  sinus, 

-^'  and  on  the  other  to  the  posterior  ethmoidal  cell  ;  and  in  addition  the 

course  of  the  optic  canal  in  these  cavities  is  shown  for  a  distance  of 
12  millimetres.  The  posterior  ethmoidal  cell  is  28  millimetres  long, 
30  millimetres  broad,  and  26  millimetres  high.  The  sphenoidal  cavities 
show  a  striking  asymmetry.  On  the  left  side  the  sinus  is  30  milli- 
metres broad.  22  millimetres  high,  and  41  millimetres  long.  On  the 
right  side  it  is  20  millimetres  broad,  22  millimetres  high,  and  39  milli- 
metres long.  The  anterior  end  of  the  left  sphenoidal  sinus  lies  asym- 
metricallv  in  the  middle  line  between  the  lamellae  of  the  nasal  septum. 

34.  The  left  sphenoidal  sinus  forms  the  middle  wall  and  floor  of 
the  left  optic  canal,  and  the  wall  of  the  left  and  middle  third  of  the 
optic  sulcus.  The  right  posterior  ethmoidal  cell  forms  the  middle  wall, 
and  to  some  extent  the  superior  wall,  of  the  right  optic  canal. 

35.  The  left  posterior  ethmoidal  cell  forms  the  middle  wall  and  floor 
of  the  left  optic  canal,  the  wall  of  the  whole  optic  sulcus,  and  the  floor 
of  the  right  optic  canal.  The  right  posterior  ethmoidal  cell  forms  the 
middle  wall  of  the  right  optic  canal. 

Group  11. 

The  frontal  sinus  of  the  one  side  comes  into  relation  with  the 
optic  nerve.     There  are  two  varieties.  ' 

36.  The  frontal  sinus  of  the  one  side  forms  the  roof  of  the  optic 
canal  of  the  same  side. 

37.  The  continuous  cavit}'  which  is  formed  by  coalesced  ethmoidal 
cells  and  by  the  frontal  sinus,  with  which  the  former  is  continuous, 
forms  the  inner  wall  of  the  optic  canal  and  the  wall  of  the  left 
third  of  the  optic  sulcus.  In  horizontal  section  this  is  illustrated  in 
Figures  97  and  98  in  my  Atlas. 

Group  12. 

The  cells  of  the  superior  turbinated  bone  of  the  one  side  are  in 
relation  to  the  optic  nerve.  ^^ 

38.  The  turbinate  bone  cells — so-called  "  bulloWcells  "  of  the  left 
superior  turbinate — form  the  floor  of  the  left  optic  canal  and  the  wall 
of  the  left  third  of  the  optic  sulcus.  This  relation  is  shown  in 
frontal  section  in  Figure  ^^.  The  cell  is  here  23  millimetres  long, 
19  millimetres  broad,  and  13  millimetres  high. 


TOPOGRAPHICAL  ANATOMY 


43 


In  order  to  complete  this  part  of  the  subject,  two  figures  are  added 
which  show  in  an  instructive  way  the  relations  of  the  accessory 
sinuses  to  the  ocular  and  orbital  nerves. 

Figure  34  represents  a  preparation  showing  the  position  of  the 
frontal  sinus,  the  anterior  and  posterior  ethmoidal  cells,  and  the 
sphenoidal  sinus,  and  the  relation  of  these  cavities  to  the  anterior  and 
posterior  ethmoidal  nerves  and  the  optic  nerves.     It  gives  a  general 


r 


/'•.  ^ 


^Ü<" 


Fig.    t,2i. — Natural  Size. 


1.  Optic  nerve.    ~ 

2.  Cell  in  the  superior  turlunal. 

3.  Superior  turbinal. 

4.  Middle  turbinal. 


5.  Middle  meatus. 

().  Inferior  turbinal 

7.  Inferior  meatus. 

8.  Maxillary  antrum. 


view  of  the  position  and  course  of  the  fourth  nerve,  the  fifth  nerve  and 
its  three  divisions,  the  third  nerve,  the  sixth  nerve,  the  optic  nerves, 
and  the  internal  carotid  artery. 

Figure  35  shows  in  sagittal  section  the  relations  of  the  anterior  and 
posterior  ethmoidal  nerves,  of  the  optic  nerve,  and  of  the  third,  fourth, 
and  sixth  nerves.  It  also  shows  the  relation  of  these  nerves  to  the 
internal  carotid  artery. 

3—2 


44 


THE  OPTIC  XERVE 


Having  described  these  thirty-eight  \-arieties,  classed  under  twelve 
groups,  with  the  aid  of  illustrations.  I  may  now  proceed  to  describe 


15« 


i',b 


Fig.  34. — Natural  Size. 


la.   Right  frontal  sinus.  12. 

lb.  Left  frontal  sinus.  13. 

2.  Anterior  ethmoidal  cell.  14. 

3.  Anterior  ethmoidal  nerve.  15« 

4.  Posterior  ethmoidal  cell.  16. 

5.  Right  sphenoidal  sinus.  17. 

6.  Posterior  ethmoidal  nerve.  18. 

7.  Left  sphenoidal  sinus.  19. 

8.  Optic  nerves  and  chiasma.  20. 

9.  Left  third  nerve.  21. 

10.  Pons.  22. 

11.  Internal  carotid  artery.  2^. 


Right  third  nerve. 
Sixth  nerve. 

Fourth  nerve — trochlear. 
,  b,  c.   Fifth  nerve — three  divisions. 
Middle  cranial  fossa. 
External  rectus. 
Eyeball. 
Superior  rectus. 
Levator  palpebra?  superioris. 
Supra-orbital  nerve. 
Superior  oblique  muscle. 
Anterior  cranial  fossa. 


further  such  anatomical  features  as  may  be  considered  of  practical 
significance  and   of   ^etiological   importance.     In   visual   disturbances 


L. 


r  ethmoidal  iierv' 
S,   Posterior  ethmoidal  ner\ 

7.  Right  optic  nerve, 

8.  Internal  carotid  artery. 


Fig.  35. — Natural  Size. 

Left  optic  nerve- 
Sixth  nerve — abducens. 

Fourth  nerve — trociücariü. 
Cerebral  peduncle. 


Corpora  quadrigemiu 


r\ 


TOPOGRAPHICAL  AX  ATOMY  49 

and  blindness  caused  by  disease  of  the  accessory  sinuses  the  following 
anatomical  conditions  play  an  important  role  : 

1.  The  bone  wall  of  the  optic  canal  and  of  the  optic  sulcus. 

2.  Dehiscence  in  the  walls  of  the  sinuses. 

3.  The  semicanalis  ethmoidalis. 

4.  The  partition  between  individual  sinuses. 

5.  The  turbinate  bone  cells. 

Each  of  these  will  be  considered  separately. 

1.  The  Bone  Wall  of  the  Optic  Canal  and  Optic  Sulcus. 

The  progress  of  an  osteitis,  liability  to  necrosis,  complications  of 
the  circulatory  system,  pressure  symptoms,  and  the  liability  to  frac- 
ture, may  be  favoured,  made  more  difticult,  or  be  prevented,  according 
to  the  thickness  of  the  bone  which  intervenes  between  the  optic  nerve 
and  its  neighbouring  structures,  such  as  the  sphenoidal  or  ethmoidal 
sinuses. 

Berger  and  Tyrmann^  first  investigated  the  degrees  of  thickness 
occurring  in  the  bone  partition  between  the  optic  nerves  and  the 
sphenoidal  sinuses.  In  three  of  their  illustrations  they  represent  these 
facts  ;  the  sections  were  frontal  and  in  the  plane  of  the  optic  foramina. 
In  the  first  illustration  this  septimi  is  "  uncommonly  thin  ";  in  the 
second  its  thickness  reaches  4  to  6  millimetres — in  this  the  bone  was 
spongy  ;  in  the  third,  on  one  side  the  bone  was  as  thin  as  paper,  and 
on  the  other  7  millimetres  in  thickness. 

From  my  own  observations,  I  find  that  between  the  most  posterior 
ethmoidal  cell  and  the  optic  canal  and  sulcus  the  bone  is  in  most 
cases  very  thin — sometimes  as  thin  as  silk  -  paper.  In  two  cases 
measured,  in  the  one  the  thickness  was  i  millimetre,  and  in  the  other 
2  millimetres. 

An  exceptionally  thin  partition  between  the  optic  nerve  and  the 
posterior  ethmoidal  cell  is  shown  in  Figure  15  (Atlas),  which  repre- 
sents a  sagittal  section. 

'  Between  the  optic  canal  and  sulcus  and  the  sphenoidal  sinuses  I 
have  more  often  found  a  thicker  partition.  It  has  varied  from  i  milli- 
metre to  5  millimetres,  9  millimetres,  and  12  millimetres. 

In  Figures  17  and  36  wide  variations  are  illustrated.  In 
Figure  17,  shown  in  frontal  section,  the  partition  between  optic  can.al 

^  Loc.  cit.,  pages  91-94. 


50 


THE  OPTIC  XERVE 


and  sphenoidal  sinus  is  thin.  But  in  Figure  36,  also  in  frontal  section, 
is  illustrated  the  thickest  partition  seen  by  me. 

In  Figure  6  the  partition  between  optic  nerve  and  sphenoidal  sinus 
is  6  millimetres  tliick. 

In  Figure  ^y,  illustrated  in  frontal  section,  the  thickness  of  bone 
between  the  chiasma  and  the  sphenoidal  sinus  is  8  millimetres. 

In  such  cases,  where  for  a  varying  length  the  optic  canal  runs  on 
the  internal  side  of  the  wall  of  sphenoidal  sinus  or  ethmoidal  cell,  its 


Fig.   36. — Natural  Size. 


1.  Left  optic  nerve. 

2.  Right  optic  nerve. 


3  and  4.   Sphenoidal  sinuses. 
^.   Septum. 
6.   Palate. 


wall  is  generally  thin.  In  Figure  10  an  optic  canal  is  represented, 
which  for  a  distance  of  12  millimetres  runs  within  the  posterior 
ethmoidal  cell,  its  upper,  inner,  and  lower  walls  being  bounded  by 
the  cell. 

Figure  32  and  also  Figure  72  (Atlas)  show  the  course  of  optic  nerves 
in  the  sinuses,  and  the  thinness  of  their  canals. 

In  Figure  32  is  shown,  in  frontal  section,  the  position  of  the  optic 
canal  in  the  sphenoidal  sinus  on  the  right  side,  and  in  the  posterior 
ethmoidal    cell   on    the   opposite  side.      Its  length  in  these  cavities 


TOPOGRAPHICAL  ANATOMY 


51 


reaches  12  millimetres  ;  its  walls  on  the  upper,  outer,  and  inner  and 
lower  surfaces  are  bounded  on  the  right  side  by  the  cavity  of  the  sphe- 
noidal sinus,  and  on  the  left  by  that  of  the  posterior  ethmoidal  cell. 


11 


13 


Fig.    t,j. — Natural  Size. 


1.  Hypophysis. 

2.  Left  optic  tract. 

3.  Right  optic  tract. 

4.  Left  internal  carotid  artery. 

5.  Right  internal  carotid  artery. 

6.  Left  sphenoidal  sinus. 

13.   Palate. 


7.  Right  sphenoidal  sinus. 

8.  Middle  turbinal. 

9.  Middle  meatus. 

10.  Inferior  turbinal. 

11.  Inferior  meatus. 

12.  Septum. 


The   position    of   the  optic  canal    in    the  posterior  ethmoidal  ce 
shown  in  Figure  11,  in  sagittal  section.     Its  length  in  this  is  10  milli 
metres,  and  it  is  surrounded  on  all  sides  b\'  the  cavit\'. 


11  is/'    7  . 


^2  THE  OPTIC  NERVE 

2.   Dehiscence  in  the  Walls  of  the  Accessory  Sinuses. 

A  dehiscence  in  a  sinus  wall  is  of  importance,  inasmuch  as,  in 
disease  of  such  a  sinus,  orbital,  intracranial,  and  optic  complications 
may  be  favoured,  or  even  caused,  by  it.  As  the  mucous  membrane 
over  a  dehiscence  of  bone  may  come  into  direct  contact  with  the 
orbital  periosteum  and  with  the  dura  and  sheath  of  the  optic  nerve, 
disease  may  spread  from  a  sinus  cavit\^  to  any  of  these  neighbouring 
structures.  In  a  similar  manner  the  bloodvessels  adjacent  to  a 
diseased  sinus  cavity  may  be  affected. 

Pathological  processes,  injury,  or  senile  atrophy  may  produce  an 
opening  in  a  sinus  wall.  Such  a  defect  in  the  bone  may  be  due  to  an 
artefact. 

As  I  have  already  discussed  these  factors  in  a  previous  article,^  I 
will  here  limit  mvself  to  the  congenital,  structural  bone  defects. 

Zuckerkandl "  describes  four  cases  of  bone  dehiscence  in  the 
maxillary  antrum,  and  Merlin^  two  cases.  I  have  not  seen  any  case. 
In  all  Zuckerkandl's  cases  the  defect  involved  not  only  the  orbital 'wall 
of  the  sinus,  but  also  the  lamina  papyracea  or  cs  planum  of  the  ethmoid, 
and  in  one  case  the  tuber- maxillae  was  involved  in  addition. 

Merlin  in  his  two  cases  observed  the  defect  in  the  floor  of  the  orbit. 
As  regards  the  frontal  sinuses,  in  the  space  which  lies  above  the 
orbital  cavity  between  bone  lamellae,  I  have  observed  in  parts  a  few 
punctate  or  linear  dehiscences  placed  in  the  roof  of  this  cavity,  and 
in  parts  extreme  thinning  of  this  bone  lamella.  Not  only  openings  for 
bloodvessels,  but  also  actual  congenital  dehiscence,  may  occur  in  the 
anterior  wall  of  the  frontal  sinus. 

Zuckerkandl  and  Helly^  have  in  one  case  observed  a  groove 
extending  upwards  from  the  middle  of  the  supra-orbital  ridge,  and  in 
this  groove  areas  were  defective,  and  produced  communications  with 
the  frontal  sinus.  In  a  patient  I  once  saw  such  a  congenital  defect 
in  the  anterior  wall  of  the  frontal  sinus.  Through  this  a  polypus  from 
the  sinus  protruded. 

Helly  observed  openings  for  the  bloodvessels,  the  channels  of  which 
brought  the  frontal  sinus  into  communication  with  the  anterior  surface 

^  Onodi,  "Dehiscence  in  the  Walls  of  the  Xasal  Accessory  Sinuses,"  Archives 
für  Laryngologie,  Bd.  XV. 

^   "  Anatomy  of  the  Xasal  Cavities,"  1893. 

^  Report  of  the  X'^aturAvissenschaftlich-^Iedizinischen  \'ercines  in  Innsbruck, 
1884-85, 1885-86. 

*  Deutsche  Zeitschrift  für  Chirurgie,  Bd.  III. 


TOPOGRAPHICAL  AX  ATOMY 


53 


of  the  frontal  bone.  Such  channels  of  smaller  and  larger  size  I  have 
observed  in  the  supra-orbital  ridge.  Those  cases  of  congenital  dehis- 
cence in  which  the  floor  of  the  frontal  sinus  and  the  lamina  papyracea 
or  OS  planum  of  the  ethmoid  are  involved  in  common  are  of  rare 
occurrence.  Zuckerkandl  found  this  in  three  cases — twice  on  the  left 
and  once  on  tlie  right  side.     Merlin  saw  it  once  on  the  left  side. 


Fig.  38. — Natural  Size. 


1.  Dehiscence. 

2.  Frontal  sinus. 

3.  Lachrymal  groove. 


4.  Maxillary  antrum. 

5.  Spheno-palatine  foramen. 

6.  Pterygo-palatine  fossa. 


I  have  seen  three  such  cases — twice  on  the  right  and  once  on  the 
left  side. 

According  I  to  the  observations  of  Denouvilliers  and  Gosselin,^ 
Winkler,^  and  Killian,^  small  or  large  openings  may  exist  in  the  inter- 

^   "Compcnd.  dc  Chir.  Prat.,"  1H32.  ^  Archiv  für  Laryngologie,  1894. 

^  MiUichener  Medizinische  Wocheiisclirifl,  1897. 


54  THE  OPTIC  XERVE 

frontal  septum,  thus  placing  the  two  frontal  sinuses  in  communication. 
Such  an  opening,  measuring  1-5  millimetres  in  diameter,  I  observed 
once.     Its  edges  were  smooth  and  rounded. 

Forty  years  ago  Hyrtl^  described  ''dehiscence  in  the  lamina 
papyracea  of  the  ethmoid  ;  more  recently  Zuckerkandl  observed  it  in 
fourteen  cases,  nine  being  on  the  left  side.  Merlin  saw  it  three  times 
— twice  on  the  left  and  once  on  the  right  side. 

In  one  case  fi\-e  dehiscences  were  present  in  this  ethmoidal  plate, 
and  through  these  the  orbital  cavity,  and  the  frontal  and  sphenoidal 
sinuses  were  placed  in  communication  with  the  ethmoidal  cells. 

I  have  found  eighteen  cases  of  dehiscence  of  the  lamina  papyracea — 
thirteen  on  the  left  and  five  on  the  right  side.  The  sagittal  measure- 
ment of  these  defects  varied  between  4  and  28  millimetres,  and  the 
vertical  between  4  and  8  millimetres.  In  this  manner  the  orbital 
cavity  communicated  with  the  ethmoidal  cells,  and  in  three  cases 
also  with  the  frontal  sinus.  Figure  ^8  shows  a  specimen  which 
illustrates  a  dehiscence  in  the  ethmoidal  orbital  plate. 

Dehiscences  of  physiological  significance  have  been  observed  by 
Zuckerkandl  in  the  form  of  small  fissures  in  the  side-wall  of  the  sphe- 
noidal sinus.  These  place  the  sinuses  in  communication  with  the 
middle  fossa  of  the  skull. 

Spec^  observed  a  defect  in  the  bone  wall  of  the  carotid  canal. 

In  several  skulls  I  have  observed  apertures  for  bloodvessels,  often 
S3m'imetrically  placed,  immediately  under  the  side-wall  of  the  base  of 
the  small  wing  of  the  sphenoid.  In  a  few  cases,  leading  to  these 
vascular  apertures  are  vascular  grooves,  in  which  more  or  less  lengthy 
linear  dehiscences  are  apparent. 

In  the  intersphenoidal  septum,  Zuckerkandl  and  Hajek  have  noted 
dehiscence,  placing  the  two  sphenoidal  sinuses  in  communication. 

The  wall  of  the  optic  canal  rarely  shows  dehiscence.  It  was  found 
twice  in  200  cases  by  Gallmaerts^  ;  in  50  cases  Holmes^  found  it 
twice  ;  in  300  cases  I  found  it  once. 

3.  Semicanalis  Ethmoidalis. 

A  canal  of  varying  length,  and  termed  by  me  the  "  semicanalis 
ethmoidalis,"^  runs  in  the  wall  of  the  frontal  sinus  or  in  the  orbital 

^  Vergangenheit  und  Gegenwart  des  Museums  für  Menschliche  Anatomie,  1869. 

^  Bardelebens  Handbuch  der  Anatomie,  1896. 

^  Annal.  d'Ocul,  1900.  ■*  Arch,  of  Ophthalm.,  1896. 

^  Onodi,  Archiv  für  Laryngologie,  Bd.  XR'  and  X\'. 


TOPOGRAPHICAL  AX  ATOMY  55 

cells  to  the  anterior  fossa  of  the  skull.  In  it,  through  these  cavities 
and  freely  covered  with  mucous  membrane,  pass  the  ethmoidal 
veins.  The  mucous  membrane  of  this  open  canal  at  one  end  touches 
the  orbital  periosteum  and  at  the  other  the  dura  mater. 

Owing  to  the  connections  of  the  ethmoidal  veins  with  the  venous 
plexuses  both  of  the  dura  mater  and  of  the  orbital  cavity,  a  thrombo- 
phlebitis may  spread  in  either  direction,  as  Zuckerkundl  and  Kuhnt 
have  pointed  out.  The  ethmoidal  veins  of  the  semicanalis  ethmoidalis 
may  in  a  similar  manner  produce  thrombosis  of  the  cerebral  and 
orbital  veins. 

Generally  a  very  short  canal — the  canalis  ethmoidalis — is  formed 
out  of  the  apposed  grooves  in  the  frontal  and  ethmoidal  bones.  It 
commences   in   the   anterior   ethmoidal   foramen,    and   ends    in    the 


Fig.   39. — Natural  Size. 

1.  Semicanalis'ethmoidalis.  3.   Fronto-orbital  cell. 

2.  Anterior  ethmoidal  foramen.  4.   Frontal  sinus. 

anterior  fossa  of  the  skull  as  a  linear  groove.  According  to  my 
observations,  the  length  of  the  canalis  ethmoidalis  varies  between 
5  and  12  millimetres. 

Such  ethmoidal  cells  as  extend  into  the  horizontal  part  of  the 
frontal  bone  I  term  the  "  orbital  cells."  There  may  be  one  or  two 
orbital  cells  that  open  into  the  middle  or  superior  meatus  of  the 
nose. 

Figure  39  illustrates  in  sagittal  section  the  course  of  the 
semicanalis  ethmoidalis  in  such  an  orbital  cell.  The  whole  course  of 
this  open  canal  is  shown,  lying  in  a  large  orbital  cell,  and  connecting 
through  this  cavity  the  anterior  fossa  of  the  skull  internally  with  the 
orbital  cavity  externally.  The  anterior  ethmoidal  foramen  is  con- 
tinued into  this  ethmoidal  open  canal,  which  for  a  distance  of  10  milli- 


56  THE  OPTIC  XERVE 

metres  passes  in  a  crescentic  course  on  the  posterior  and  inner  wall  of 
the  orbital  cells,  to  end  in  the  anterior  cranial  fossa. 

Three  times  have  I  observed  the  semicanalis  ethmoidalis  in  the 
frontal  sinus,  with  a  length  varying  between  5  and  8  millimetres. 
Nine  times  did  it  manifest  itself  in  the  first  orbital  cell,  with  a  length 
varying  between  7  and  10  millimetres,  and  in  the  second  orbital  cell 
four  times,  with  a  length  of  between  4  and  10  millimetres.  Twice  in 
association  with  a  dehiscence  in  the  lamina  papyracea  did  I  see  a 
semicanalis  ethmoidalis  in  the  orbital  cells  ;  and  once,  as  is  illus- 
trated in  Figure  97  (Atlas)  a  semicanalis  16  millimetres  in  length  was 
found  passing  downwards  on  the  lateral  wall  of  the  frontal  sinus.  In 
this  skull  the  cavity  in  the  ethmoid  was  continuous  with  the  frontal 
sinus,  and  the  distance  between  the  anterior  wall  of  the  frontal  sinus 
and  the  anterior  ethmoidal  foramen  amounted  to  23  millimetres. 

4.  Septa  between  Individual  Accessory  Sinuses. 

I  will  now  discuss  such  very  thin  septa  between  individual  sinuses 
as  I  have  personally  observed,  for  these  have  a  practical  importance  in 
the  spread  of  disease  and  in  the  production  of  perforations.  The  max- 
illary antrum  may  have  a  wall  common  to  it  and  to  the  sphenoidal  and 
ethmoidal  sinuses.  And,  as  I  was  the  first  to  point  out,  the  maxillary 
and  sphenoidal  sinuses  may  be  so  large  as  to  lie  in  direct  apposition. •*- 

Figure  40  demonstrates  this  relationship,  as  seen  in  horizontal 
section.  The  maxillary  antrum  was  42  millimetres  long  and  36  milli- 
metres broad  ;  the  sphenoidal  sinus  37  millimetres  high,  47  millimetres 
broad,  and  35  millimetres  long.  The  width  of  septum  common  to 
these  ca\-ities  was  10  millimetres,  and  it  formed  at  the  same  time  the 
maxillary  part  of  the  anterior  sphenoidal  wall.  Such  partitions 
common  to  these  two  cavities  I  have  observed  in  six  cases. 

The  width  of  this  partition — that  is,  the  maxillary  part  of  the 
anterior  wall  of  the  sphenoidal  sinus — was  in  two  cases  4  millimetres, 
in  one  6  millimetres,  in  another  8  millimetres,  and  in  two  other  cases 
10  millimetres. 

Thin  septa  are  also  present  between  the  maxillary  antrum  and  the 
ethmoidal  cells.  Such  a  partition  common  to  the  maxillary  antrum 
and  the  posterior  ethmoidal  cells,  present  on  both  sides,  is  illustrated 
in  Figure  41. 

The  extreme  thinness  of  such  a  septum  is  illustrated  in  Figure  42 

^  Archiv  für  Laryngo.'ogie,  Btl.  XI. 


TME:- 


Vt 


^^-^f'" 


Maxillary  antrum. 

6.  Middle  tiirbinal. 

Sphenoidal  sinus. 

7.  Cell  in  middle  turbinal. 

Pars  maxillaris  antri. 

8.  Naso -lachrymal  duct. 

Superior  turbinal. 

TOPOGRAPH  IC  A  L  AX  A  TO  MY 


6i 


in  frontal  section,  and  in  Figure  48  its  presence  on  both  sides  is  shown, 
the  section  being  horizontal. 

The  frontal  sinus  may  ha\'e  a  septum  common  to  it  and  to  the 
sphenoidal  sinus  and  the  posterior  ethmoidal  cells.  The  septum 
that  intervenes  between  the  two  frontal  sinuses  may  He  sagittally, 
or,   where    there    is    asymmetry,   may  assume   an    oblique   position. 


Fig.  41. 

X 

\TUR.\L 

Size. 

I. 

Maxillary  antrum. 

7- 

Cyst. 

2. 

Posterior  ethmoidal  cell 

S. 

Superior  meatu? 

3- 
4- 

Left  sphenoidal  sinus. 
Superior  tinM)inal. 

9. 
10. 

Middle  meatus. 
Inferior  meatus 

5- 

Middle  turbinal. 

1 1. 

Septum. 

6. 

Inferior  turbinal. 

I  J. 

Palate. 

In  Figure  103  (Atlas)  a  sagittal  septum  medially  ]:)la(H'd  is  sliown. 
In  Figure  43  an  asymmetry  of  the  frontal  sinuses  is  shown  in 
sagittal  section.  In  this  the  left  sinus  covers  the  right  over  a  breadth 
of  15  millimetres,  and  upwards  it  extends  yet  farther  for  30  milli- 
metres. In  addition  there  is  a  horizontal  septum  comiuon  to 
these  two  sinuses  besides  the  vertical  one.     There  may  be  only.one 


62 


THE  OPTIC  XERVE 

2 


12  11 

Fig.  42. — Natural  Size. 


I. 

Opening  of  sphenoidal  sinus. 

/• 

Middle  turbinal. 

2. 

Posterior  ethmoidal  cell. 

8. 

Middle  meatus. 

^• 

Septum. 

9. 

Maxillarv  antrum 

4- 

Xasal  part  of  sphenoidal  sinus  wall. 

10. 

Inferior  turbinal. 

Superior  turbinal. 

1 1. 

Inferior  meatus. 

6. 

Superior  meatus. 

12. 

Palate. 

Fig.  43. — Xatur.\l  Size. 
I.   Right  frontal  sinus.  2.  Left  frontal  sinus. 


TOPOGRAPHICAL  ANATOMY 


63 


frontal  sinus,  or  even  both  may  be  absent.  In  such  cases  an  inter- 
frontal  septum  is  non-existent.  Figure  10  (Atlas)  illustrates  in  sagittal 
section  a  septum  common  to  the  anterior  ethmoidal  cells  and  the 
frontal  sinuses.  Figures  44  and  45  illustrate  a  septum  common  to 
those  ethmoidal  cells  that  stretch  to  the  region  of  tlie  frontal  sinuses — 
the  bulla  frontalis  and  the  frontal  sinus.  In  Figure  44  there  is  well 
seen  in  sagittal  section  the  thin  septum  between  the  bulla  frontalis, 
which  is  17  millimetres  long,  22  millimetres  high,  and  21  millimetres 
broad  ;  and  the  frontal  sinus,  which  is  25  millimetres  long,  6  milli- 
metres high,  and  34  millimetres  broad. 

In  Figure  45  there  is  shown,  in  frontal  section,  on  both  sides  the 
septum  common  to  the  bulla  fron  talis  and  the  frontal  sinus.  On  the  right 
side  the  frontal  sinus  is  20  millimetres  long,  30  millimetres  broad,  and 


Fig.  44. — Natural  Size. 

I.   Frontal  sinus.  2.   I'Yontal  bulla. 

3.   Fronto-orbital  cell. 


II  millimetres  high,  and  on  the  left  14  millimetres  long,  30  millimetres 
broad,  and  11  millimetres  high.  On  the  right  side  the  bulla  frontalis 
is  20  millimetres  long,  13  millimetres  broad,  and  20  millimetres  high, 
and  on  the  left  side  20  millimetres  long,  13  millimetres  broad,  and 
20  millimetres  high.  That  is  identically  the  samt^  as  on  the  right 
side. 

The  following  sagittal  sections  illustrate  a  septum  common 
to  the  frontal  sinus  and  an  orbital  cell.  Figure  46  shows  a  thin 
arched  septum  between  the  frontal  sinus,  which  is  23  millimetres  high, 
30  millimetres  broad,  and  13  millimetres  long,  and  an  orbital  cell 
27  millimetres  long,  19  millimetres  high,  and  29  millimetres  broad. 

Figure  36  (Atlas)  shows  a  communication  between  the  frontal 
sinus  and  the  orbital  cell. 


64 


THE  OPTIC  XERVE 


9           6    12  13 
Fig.  4;. — Natural  Size. 

1.  Frontal  sinus.  7-   Maxillary  antrum. 

2.  Frontal  bulla.  8.   Inferior  turbinal. 
T,.   Partition  between  frontal  sinus  9-   Inferior  meatus. 

and  frontal  bulla.  10.  Superior  turbinal. 

4.  Eveball.  H-   Opening  of  maxillary  antrum. 

5.  Duct.  13.   Septum. 

6.  Middle  turbinal.  i3-   Palate. 


2  1  1 

Fig.  46. — Natural  Size. 
I.  Frontal  sinus.  2.  Fronto-orbital  cell. 


TOPOGRAPHICAL  ANATOMY  65 

Figure  47  shows  an  exceptionally  thin  septum  common  to  the 
frontal  sinus  which  is  iq  millimetres  long,  35  millimetres  high,  and 
32  millimetres  broad,  and  an  orbital  cell  which  is  25  millimetres  long, 
28  millimetres  broad,  and  13  millimetres  high. 

Figure  26  (Atlas)  illustrates  a  case  in  which  the  frontal  sinus  is 
separated  from  the  posterior  ethmoidal  cell  by  a  septum  common 
to  the  two  cavities  ;  and  Figure  8  shows  a  specimen  in  which  the 
ethmoidal  cells  form  a  continuous  cavity  with  the  frontal  sinus. 

In  Figures  31,  ;^y,  52  (Atlas),  are  illustrated  in  sagittal  section 
the  septa  common  between  the  frontal  sinuses  and  both  orbital 
cells,  and  also  the  communications  between  individual  cavities. 
Figure  31  shows  a  thin  septum  between  the  frontal  sinus  and  the 
first  orbital  cell,  and  a  thin  septum  between  the  first  and  second 
orbital  cells.      In  Figure  ;^y  is  shown    a    complete    septum   between 

211  2 

Fig.  47. — Natural  Size. 
I.  Frontal  sinus.  2.  Fronto-orbital  cell. 

the  first  and  second  orbital  cells,  and  a  communication  between 
the  first  orbital  cell  and  the  frontal  sinus.  In  Figure  52  a  com- 
plete septum  separates  the  frontal  sinus  and  the  first  orbital  cell, 
and  there  is  a  communication  between  the  first  and  second  orbital  cells. 
In  Figure  38  (Atlas)  a  communication  is  shown  between  the  frontal 
sinus  and  the  two  orbital  cells.  The  frontal  sinuses  may  extend  far 
back,  even  up  to  the  level  of  the  optic  foramina,  and  in  such  cases 
they  may  be  separated  from  the  posterior  ethmoidal  cell  as  well  as 
from  the  sphenoidal  sinus  by  quite  a  thin  septum. 

Figure  65  (x\tlas)  illustrates  a  preparation  in  which  the  frontal 
sinuses  extend  far  back  over  the  orbital  roofs,  and  on  the  right  side 
the  frontal  sinus  is  only  separated  from  the  right  sphenoidal  sinus  by  a 
thin  septum,  and  on  the  left  side  from  the  left  posterior  ethmoidal 
cell  by  a  thin  septum.  This  septum  between  the  sphenoidal  sinus 
and    the    frontal   sinus — in   other    words,    the    pars    frontalis    of    the 

4 


66 


THE  OPTIC  XERVE 


anterior  wall   of   the  sphenoidal   sinus — measures   12   millimetres  in 
breadth. 

In  Figure  66  (Atlas)  a  specimen  is  illustrated  in  frontal  section  in 
which  the  frontal  sinus  extends  back  to  the  region  of  the  sphenoidal 
sinus  and  of  the  optic  nerve,  and  is  separated  from  the  posterior 
ethmoidal  cell  by  a  thin  partition. 


Fig.  48. — Natural  Size. 


1.  Ethmoidal  cells. 

2.  Sphenoidal  sinus. 


3.  Xaso-frontal  duct. 

4.  Septum. 


In  Figures  48  and  49  the  septa  between  individual  ethmoidal 
cells  are  shown. 

Finally,  there  remain  to  be  considered  the  septa  between  the 
posterior  ethmoidal  cells  and  the  sphenoidal  sinuses.  The  posterior 
ethmoidal  cells  may  lie  in  series  above  the  sphenoidal  sinus,  or  may  lie 
in  front  of  it.  The  septum  intervening  mav  be  vertical  or  horizontal 
or  oblique.     This  area  of  the  sphenoidal  wall,  the  pars  ethmoidalis 


TOPOGRA  PH  IC  A  L  A  XA  TOM  Y 


67 


of  that  wall,  may  vary  in  width  between  i  millimetre  and  18  milli- 
metres. In  Figure  49  the  septum  between  the  posterior  ethmoidal  cell 
and  the  sphenoidal  sinuses,  as  well  as  the  intersphenoidal  septum,  are 
shown  in  horizontal  section.  In  this  specimen  the  intersphenoidal 
septum  lies  in  a  sagittal  plane,  but  in  the  presence  of  asymmetry  of 


Fig.  49. — Natural  Size. 


1,1.    Posterior  ethmoidal  cells. 
2,  2.   Sphenoidal  sinuses. 
2,,  'i-   Olfactory  lissures. 


4.  4.  4,  4  4.    .\nterior  ethmoidal  celb 

5.  I'Yontal  sinus. 

6.  Surface  of  anterior  cranial  fossa. 


the  sinuses  it  may  lie  in  \-ari()us  j)lanes.  and  mav  have  bendings,  or,  in 
the  absence  of  one  sinus,  may  be  non-c.xistcnt. 

In  Figure  41  a  rare  relationship  is  shown  in  frontal  section. 
The  right  sphenoidal  sinus  has  a  septum  common  between  it  and  both 
posterior  ethmoidal  cells.  In  Figure  32  a  similar  relation  is  shown 
between  the  left  sphenoidal  sinus  and  both  posterior  ethmoidal  cells. 

4—2 


68  THE  OPTIC  NERVE 

Figure  15  shows  in  sagittal  section  the  most  posterior  ethmoidal 
cell  placed  above  the  sphenoidal  sinus,  and  an  exceptionally^  thin 
septum  between  the  two  cavities. 

5.  Turbinate  Bone  Cells,  or  Osseous  Bullae. 

The  osseous  bullae,  which  I  term  the  "  turbinate  bone  cells,"  are  a 
developmental  anomaly.^  Owing  to  disease,  they  may  reach  a  very 
varying  size.  They  may  be  present  in  both  superior  and  middle 
turbinated  bones.  Those  of  the  superior  turbinated  bone  may  come 
into  relation  with  the  optic  nerves.  As  they  ma\'  produce  pressure 
symptoms  due  to  the  enlargement  and  distension  caused  by  patho- 
logical changes,  their  clinical  importance  is  considerable.  I  have  seen 
such  cells  nine  times  in  the  middle  turbinate  and  twice  in  the  superior 
turbinate.  Only  in  two  cases  did  they  open  into  the  middle  meatus  ; 
in  other  cases  they  opened  into  the  superior  meatus.  In  length  they 
varied  from  8  to  20  millimetres,  in  breadth  from  5  to  14  millimetres, 
in  height  from  7  to  16  millimetres. 

In  Figure  18  (Atlas)  a  cell  in  the  middle  turbinate  is  shown  in 
sagittal  section  ;  it  is  17  millimetres  long,  20  millimetres  high,  and  14 
millimetres  broad.  In  Figure  33,  in  frontal  section,  a  cell  is  shown  in 
the  upper  turbinated  bone  ;  it  is  23  millimetres  long,  19  millimetres 
broad,  and  13  millimetres  high.  This  cell  reaches  posteriorly  up  to 
the  region  of  the  optic  nerves. 

^  Ünodi,  Archiv  für  Laryngologie,  Bd.  XV. 


II 

CLINICAL  CONSIDERATIONS 

Our  knowledge  of  the  production  of  visual  disturbance  by  accessory 
sinus  disease  is,  unfortunately,  still  defective. 

Traumatic  lesions  are  shown,  through  post-mortem  examination, 
to  be  produced  by  swellings  arising  from  the  naso-phaiynx,  from  the 
sphenoidal  sinuses,  the  ethmoidal  cells,  or  from  the  ethmoid  bone 
itself.  Either  by  pressure  or  through  circulatory  interference  the 
optic  nerves  become  impaired  in  function.  Post-mortem  examinations 
also  reveal  traumatic  lesions  of  the  optic  nerve  caused  by  fracture  or 
fissuring  in  the  region  of  the  sphenoid,  or  the  involvement  of  the 
nerve  in  a  hyperostosis  of  the  wing  of  the  sphenoid  causing  narrowing 
of  the  optic  foramen.  Post-mortem  examination  further  reveals 
the  association  of  accessory  sinus  suppuration  with  perforation  of 
sinus  walls,  caries  and  necrosis,  basal  meningitis,  extia-  and  intradural 
abscess,  and  thromboses  of  the  cavernous  sinus  and  ophthalmic 
veins.  There  are  only  a  few  observations,  both  microscopic  and 
bacteriological,  which  prove  the  source  and  spread  of  the  infection 
by  continuity  and  by  the  bloodvessels.  In  the  post  -  mortem 
examination  there  remain  to  be  demonstrated  the  manner  and  course 
of  the  spread  of  the  disease,  with  causal  relationships  ;  also  micro- 
scopic and  bacteriological  investigation  of  the  diseased  sinuses  and 
of  the  optic  nerves.  What  is  also  lacking  is  the  examination  of  the 
ethmoidal  veins,  the  central  \'ein  of  the  retina,  and  the  venous 
radicles  arising  from  the  diseased  sinuses  ;  and  we  also  need  a 
description  of  the  exact  relations  of  the  optic  nerves  to  the  diseased 
and  healthy  sinuses. 

To  the  isolated  pathological  facts  at  our  disposal  we  can  add 
observations  made  clinically  and  draw  deductions  from  these.  Such 
observations  concern  the  clinical  bearings  of  visual  disturbances  and 
blindness  upon  disease  of  intranasal  origin,  and  the  production  of 
optic  neuritis  and  atrophy  in  the  optic  canal.  To  preface  a  con- 
sideration of  these  clinical  symptoms,  I  may  add  that  various  causes 

69 


70  THE  OPTIC  XERVE 

have  been  established  bv  ophthabiiologists  as  productive  of  optic 
neuritis  and  optic  atrophv.  Optic  neuritis  or  optic  atrophy  may 
be  present  in  disease  of  the  nasal  accessor}^  sinuses  without  ha\'ing 
been  caused  bv  it.  Even  in  cases  where  the  nasal  origin  of  such  optic 
nerve  disturbance  can  no  longer  be  doubted,  we  must  still  bear  in  mind 
the  possibility  of  accidental  association. 

Cases  have  been  observed  where  the  unfavourable  progress  of  an 
optic  neuritis  was  not  in  the  slightest  degree  influenced  b\'  operation 
on  diseased  accessorv  sinuse>  ;  and,  on  the  other  hand,  in  cases  of  acces- 
sory sinus  suppuration,  in  which  operation  was  refused,  spontaneous 
cure  of  an  optic  neuritis  that  was  present  has  been  reported.  Cases, 
too,  are  not  uncommon  in  which  optic  neuritis  or  optic  atrophy  is 
in  existence,  where  the  ophthalmologist  can  discover  no  cause  and 
the  rhinologist  finds  normal  nasal  ca\'ities.  It  is  seen  thus  that 
accessor}"  sinus  suppuration  mav  be  present  in  cases  of  optic  neuritis 
or  optic  atrophy,  and  be  apparentlv  in  causal  association,  and  yet 
be  independent  and  unassociated  with  it. 

The  clinical  pictures  of  these  cases  of  true  and  apparent  causal 
association  of  accessory  sinus  ^^•ith  optic  nerve  disease  so  merge  into 
each  other  that  a  true  diagnosis  mavbe  vervdifhcult.or  even  impossible, 
clinicall3\  I  mention  this,  as  it  is  my  conviction  that  false  inferences 
are  not  infrequently  made  in  these  cases. 

We  now  pass  on  to  the  aetiolog}^  of  such  visual  disturbances. 

Mechanical  and  traumatic  lesions  have  been  proved  to  be  respon- 
sible, b}'  post-mortem  examinations.  Swellings  or  tumours  in  the 
region  of  the  optic  nerves,  and  arising  from  the  accessor^"  sinuses, 
may  cause  symptoms  through  direct  pressure.  Bering  and  Wicher- 
kiewicz^  have  shown  a  case  in  which  a  normal  optic  nerve  lav  embedded 
in  a  growth.  Ponfick,  also  Schmidt-Rimpler,-  and  Onodi,^  have  sho\\Ti 
that  in  sarcoma  of  the  body  of  the  sphenoid  the  optic  nerves  may 
remain  intact.  Virchow^  and  Manz^  have  shown  in  post-mortem 
dissections  that  in  earl\-  youth  developmental  anomalies,  premature 
ossification,  and  hyperostosis  in  the  base  of  the  skull ,  may  cause  blind- 
ness, in  some  cases  through  constriction  of  the  optic  nerve  at  the 
optic  foramen. 

Enslin*^    and    Goldzieher"    have    obser\-ed    blindness    in    cases    of 

^  Berliner  Klinische  Wochenschrift,  1882. 

-  Archiv  für  Laryngologie.,  Bd.  XVII.  ^  Ibid. 

*   "  Krankhafte  Geschwülste."  ^  Heidelberger  Berichte,  1S87. 

^  Graefes,  Archiv  für  Ophthalmologie,  Bd.  LVIII. 

"  Budapesti  Orvosi  ujsr.g  Szcnitszet,  1904. 


CLINICAL  CONSIDERATIOXS  71 

dolichocephalics.  In  two  cases  I  have  seen  anosmia  associated  with 
blindness,  due  to  constriction  of  the  foramina  of  the  olfactory  and 
optic  nerves. 

Direct  and  indirect  fracture  of  the  optic  canal  and  injury  to  the 
optic  nerves  is  known.  Holder^  reports  fifty-three  cases  of  this 
nature.  In  all  of  them  the  cctiology  was  established  by  post-mortem 
examination. 

In  dealing  with  accessory  sinus  suppuration  as  a  cause  of  visual 
disturbance,  we  have  to  consider  the  nature  and  spread  of  the  infection, 
and  the  complications  due  to  infection  of  the  bloodvessels,  as  well  as 
the  presence  of  any  bone  dehiscence.  From  post-mortem  examina- 
tions, bone  necrosis,  thrombo-phlebitis,  meningitis,  orbital  cellulitis, 
cerebral  abscess,  etc.,  are  found  associated  with  accessory  sinus 
suppuration.  Such  findings  are,  however,  as  yet  incomplete.  The 
exact  path  of  the  infective  disease,  the  changes  in  the  walls  of  the 
accessory  sinuses  and  in  the  bloodvessels,  especially  in  the  ethmoidal 
veins  and  central  vein  of  the  retina,  and  microscopic  examination  of 
the  optic  nerves — these  still  remain  to  be  investigated.  The  paths  of 
infection  in  two  cases,  through  direct  continuity  and  through  blood- 
vessels, have  been  carefully  determined  by  Ortmann^  and  Hajek.^ 

In  Ortmann's  case  an  empyema  of  the  sphenoidal  sinus  was 
associated  with  an  extradural  abscess  in  the  sella  turcica,  and  throm- 
bosis of  both  cavernous  sinuses.  The  bone  of  the  sella  turcica  was  of  a 
brownish-red  colour.  The  following  observation  was  made  on  micro- 
scopic examination  :  "  It  could  be  determined  that  numerous  diplo- 
cocci  lying  between  leucocytic  infiltrations  had  invaded  both  the 
mucous  membrane  and  periosteum  of  the  sphenoidal  cavity.  These 
showed  numerous  small  hcemorrhages  as  well.  Microscopic  sections 
of  the  sphenoidal  body  and  its  membranes  also  revealed  these  diplo- 
cocci." 

Thus  the  spread  of  the  disease  was  by  direct  continuity  to  the 
meninges.  The  inflammation  in  the  sphenoidal  sinus,  and  the  damming 
up  of  its  secretion,  led  to  periostitis  and  purulent  osteomyelitis,  which 
infected  both  dura  and  pia  mater. 

In  Hajek's  case  ethmoidal  suppuration  was  associated  with  menin- 
gitis. On  post-mortem  examination,  a  diffuse  acute  pachymeningitis 
interna  and  leptomeningitis  with  a  fibrinous  purulent  exudate  was 
found  both  over  the  base  and  convexity  of  the  brain.     Acute  hydro- 

^  Berlin,  "  Graefe-Sämisch'  Handbuch."  -   Virchow's  Archiv,  Bd.  CXX. 

^  Archiv  für  Laryngologie,  Bd.  XVIII. 


72  THE  OPTIC  NERVE 

cephalus  of  the  ventricles  was  present.  The  ethmoidal  cells  on  the 
left  side  were  inflamed,  and  the  maxillary  antra  showed  oedema  of 
their  mucous  membrane.  The  intracranial  exudate  revealed  Strepto- 
coccus pvogenes.  Hajek,  after  a  microscopic  investigation,  concludes 
as  follows  with  reference  to  the  path  of  infection  :  "  We  had  to  deal 
with  infiltration  of  the  inflamed  mucous  membrane  tissue  by  virulent 
streptococci,  and,  further,  with  an  invasion  of  the  bloodvessels  by  the 
streptococci.  On  account  of  the  well-known  venous  anastomoses 
between  the  mucous  membrane  of  the  ethmoidal  cells  and  the  dura 
mater,  without  there  being  any  involvement  of  bone  or  bone  marrow, 
the  meninges  became  rapidly  infected."  Westenhöfer's^  previous 
statements  that  a  cerebro-spinal  meningitis  may  arise  through  the 
lymphatic  channels  have  not  been  proved  by  microscopic  examina- 
tion, and  he  himself  in  a  recent  statement-  says  that  the  lymph 
channels  must  yet  be  proved  by  microscopic  research  to  be  the  paths 
of  infection.  The  material  clinically  observed  by  me,  and  which 
came  to  the  post-mortem  room,  as  well  as  other  collected  material, 
are  being  examined  as  to  their  pathology  by  Dr.  B.  Entz,  assistant  to 
the  Pathological  Anatomical  Institute  at  Budapest.  These  researches 
are  as  yet  incomplete. 

Such  observations,  clinical  and  pathological,  as  concern  com- 
plications possible  to  individual  diseased  accessory  sinuses  will  now 
first  be  reviewed,  and  later  the  aetiology  will  be  more  closely  con- 
sidered. These  observations  will  be  shortly  discussed  and  taken  in 
groups. 
I  Foucher^  points  out  as  complications  of  disease  of  the  maxillary 
,.  antra  orbital  phlegmon  and  thrombo-phlebitis  of  the  pterygoid  and 

y^  ^^^  ophthalmic  venous  plexuses.  Mair^ describes  a  case  with  caries  of  the 
ethmoid,  perforation  of  the  lamina  cribrosa,  and  abscess  in  the  pre- 
frontal convolutions  of  the  cerebrum  ;  and  Panas'''  found  a  case  with 
necrosis  of  a  part  of  the  orbital  roof,  and  purulent  periostitis  and 
abscess  in  the  frontal  convolutions  ;  and  Dmochovszky*^  found  several 
perforations  in  the  walls  of  the  maxillary  antrum,  perforation  into  the 
sphenoidal  sinus,  purulent  meningitis,  intradural  abscess,  and  abscess 
in  the  frontal  lobes. 

^  Berliner  Klinische  Wochenschrift,  1905. 
^  Deutsche  Medizinische  Wochenschrift,  1906. 

^  Courtaix,    "  Recherches  Cliniques   sur  Ics   Relations   Patholog.   entrc   V(E\\ 
et  les  Dents,"  Paris,  1895. 

*  Edinburgh  Medical  Journal,  1866.  •^  Archiv.  d'Ophthalmol.,  1885. 

®  Archiv  für  Laryngologie,  1895,  Bd.  III. 


CLINICAL  CONSIDERATIONS  y^ 

Westermayer^  had  a  case  with  perforation  into  the  ptervgo-palatine 
fossa,  caries  and  perforation  in  the  large  wing  of  the  sphenoid,  and  an 
abscess  in  the  temporal  lobes. 

■  The  following  conditions  have  been  found  in  disease  of  the  frontal 
sinuses  :  In  Bousquet's^  case  perforation  of  the  floor  and  posterior 
wall,  and  abscess  in  the  frontal  lobes.  In  Koehler's^  case  perforation 
of  the  posterior  wall,  intradural  abscess,  and  basilar  meningitis.  In 
Schindler's^  case  perforation  of  the  posterior  wall,  abscess  in  the  frontal 
lobe,  and  pyaemia.  In  Zirm's  case^  there  was  thrombo-phlebitis 
of  the  orbital  and  cavernous  veins,  with  orbital  cellulitis  and 
purulent  emboli.  In  Huguenin's^  case  there  was  encephalitis  and 
meningitis.  In  MüUer's'''  case  abscess  over  the  left  parietal  bone,  a 
perforation  communicating  with  an  extradural  abscess,  and  menin- 
gitis over  the  right  side  of  the  convexity  of  the  brain.  In  Paulsen's^ 
case  there  was  a  perforation  of  the  posterior  wall  of  the  frontal  sinus, 
and  of  the  dura,  intradural  abscess,  and  meningitis.  In  Huguenin's^ 
case  perforation  of  the  posterior  wall  of  the  frontal  sinus  had  led  to 
purulent  pachy-  and  leptomeningitis,  intradural  abscess,  and  fibrous 
adhesion  between  the  membranes  and  the  cerebral  surface.  In 
Knapp's^^  case  there  were  present  perforation  of  the  posterior  wall 
of  the  frontal  sinus,  periostitis  of  the  orbital  plate  of  the  frontal  bone, 
adhesion  of  the  dura  to  a  discoloured  cerebral  surface,  and  commencing 
abscess  in  the  frontal  lobes.  In  Bourot-Lecard's^^  case  periostitis  of 
the  anterior  and  orbital  wall  of  the  frontal  bone,  thrombo-phlebitis 
of  the  orbital  veins  and  of  the  cavernous  sinus,  and  purulent 
meningitis  were  found  ;  and  in  Redtenbacher's^^  case  perforation 
of  the  posterior  wall  of  the  frontal  sinus,  with  intradural  and  frontal 
abscess.  In  Lennox  Browne's^^  case,  with  perforation  of  the  posterior 
wall  of  the  frontal  sinus,  there  were  combined  pachy-  and  lepto- 
meningitis. In  Hoppe's^^  case  there  was  a  congenital  defect  of  the 
posterior  wall  of  the  frontal  sinus,  and  meningitis  of  botli  base  and 
convexity  of  the  brain.     In   Krccke's^^  case  extradural  abscess  and 

^  Münchener  Medizinische  Wocliensclirift,  1893. 

^  Progress  Mi'dical,  1877.  ^  Charitc-Annalen,  1892. 

*  Archives  de  Med.  et  de  Pharm. -niilitaires,  1892. 

•^   Wiener  Medizinische  Wochenschrift,  1892. 

®  Korrespondenzblatt  der  Schweizer  Arzte,  1882. 

^   Wiener  Klinische  Wochenschrift,  1895. 

^  Hospitals  Tidende,  1861.  ^  Loc.  cit. 

^^  Archiv  für  Angenhei' künde,  1880.  ^^  Bordeaux  Med.,  1875. 

^2  Wiener  Medizinische  Blätter,  1892.  ^^  Journal  of  Laryngology,  vol.  \-ii. 

^*  Klinische  Monatsblätter  für  Augenheilkunde,  1893. 
^^  Münchener  Medizinische  Wochenschrift,  1894. 


74  THE  OPTIC  XERVE 

abscess  in  the  frontal  lobe,  with  rupture  into  a  lateral  ventricle 
were  found.  In  the  case  of  Wallenberg^  there  was  perforation  of 
posterior  and  inferior  walls  and  intradural  abscess.  In  Silex's-  case 
there  was  perforation  of  the  posterior  and  inferior  M-alls  of  the  frontal 
sinus,  with  cerebral  abscess  on  both  sides.  In  Milligan's^  case  septic 
thrombosis  and  meningitis.  In  E.  Fränkel's"*  case  thrombo-phlebitis 
of  the  superior  longitudinal  sinus,  with  pyaemia.  In  Macewen  and 
Millar's^  case  thrombo-phlebitis  of  the  superior  longitudinal  sinus 
had  occurred  in  the  neighbourhood  of  the  frontal  sinus,  and  also 
extra-  and  intradural  abscess,  purulent  meningitis,  and  pyaemia.  In 
Roth's'^'  case  abscess  of  the  tissues  over  the  frontal  bone,  purulent 
meningitis,  encephalitis  on  the  right  side,  and  abscess  in  the  frontal 
lobe  on  the  left  side.  Carver"  reports  thrombosis  of  the  superior 
longitudinal  sinus,  with  meningitis  over  the  convexity  of  the  brain, 
and  Cholle^  reports  two  cases  of  meningitis. 

In  disease  of  the  ethmoidal  cells,  Begbie^  reports  perforation  of 
the  lamina  cribrosa  of  the  ethmoid,  and  abscess  of  the  frontal  lobe. 
Schäffer^*^  reports  perforation  of  the  lamina  papyracea,  orbital  peri- 
ostitis, and  perforation  of  the  orbital  roof,  with  an  abscess  in  the  frontal 
lobe.  Pauncz^^  and  Jacubasch^-  found  cerebral  abscess  associated 
with  ethmoidal  disease,  and  Ogston,^^  Warner, ^"^  and  Ewald, ^^  found 
meningitis.  Trousseau^*^  had  a  case  with  necrosis  of  the  ethmoid  and 
meningitis,  and  Hajek^"  had  one  with  meningitis. 

In  suppuration  of  the  sphenoidal  sinuses,  Horner^^  had  a  case, 
with  blindness  and  exophthalmos  on  the  left  side,  which  on  post- 
mortem examination  showed  caries  of  the  basi-sphenoid  and  neigh- 
bouring parts.  Panas^^  reports  a  case  which,  as  a  result  of  osteitis 
of  the  sphenoid,  had  orbital  phlegmon,  exophthalmos,  and  blindness. 
In  Rouge's-^  case  there  were  present  di\ergent  strabismus,  and  loss 

^  Xeiirologisches  Zentralblatt,  1895. 

^  Berliner  Klinische  Wochenschrift,  1896. 

^  The  Medical  Chronicle,  1899.  *    Virchow's  Archiv,  Bd.  CXLIII. 

'^  Killian,  "Verein  Süddeutscher  Laryngo logen,"  1900. 

"  Wiener  Klinische  Wochenschrift,  1899.  ^  British  Medical  Journal,  1883. 

^  Archiv.  Internat,  de  Laryng.,  1906.  ^  Medical  Times  and  Gazette,  1852. 

^'  Prager  Medizinische  Wochenschrift,  1883. 

^'  Archiv  für  Laryngologie,  Bd.  XIII. 

^-  Berliner  Klinische  Wochenschrift,  1873. 

'^  British  Medical  Journal,  1S85.  '  ^*  Ibid. 

^"^  Deutsche  Medizinische  Wochenschrift,  1890. 

^^  Cliniq.  Medic.  Deutsche,  2  Aufl.,  1866. 

^'  Archiv  für  Laryngologie,  Bd.  XVIII. 

^^  Klinische  Monatsblätter  für  Augenheilkunde,  1S63. 

^^  Soc.  de  Chir.  de  Paris,  1S73.  -'^  L' Union  Medic,  1872. 


CLINICAL  CONSIDERATIONS  75 

of  vision  on  the  left  side,  and  on  post-mortem  examination  a  purulent 
periostitis  associated  with  suppuration  in  the  left  sphenoidal  sinus 
was  found.  In  Raymond's^  case  blindness  and  exophthalmos  were 
present  on  both  sides,  and  on  post-mortem  examination  it  was  found 
that  there  was  a  purulent  basal  meningitis  which  involved  the  optic 
chiasma,  along  with  thrombosis  of  the  cavernous  sinus  and  of  the 
ophthalmic  veins,  due  to  caries  and  perforaticm  in  the  roof  of  the 
sphenoid.  In  Ortmann's^  case  there  was  an  extradural  abscess,  situated 
in  the  sella  turcica,  also  thrombosis  of  both  cavernous  sinuses,  and 
periostitis  and  suppuration  in  both  sphenoidal  sinuses.  In  Grim- 
wald's^  case  there  was  basilar  meningitis,  and  pus  in  the  sphenoidal 
sinuses  and  maxillary  antra.  Vince^  reports  perforation  in  the  basilar 
apophysis  with  meningitis  ;  Thiroloix,^  extradural  abscess  in  the  sdla 
turcica,  and  meningitis  ;  Flatau,*^  perforation  of  the  posterior  wall  of 
the  sphenoidal  sinus,  and  meningitis  ;  Zöckendörler,"  meningitis  ; 
Pekastovsky,^  necrosis  in  the  sella  turcica,  and  meningitis,  along  with 
thrombosis  of  the  longitudinal  sinus.  In  Scholz's'-^  case  were  found 
purulent  periostitis  and  perforation  over  the  upper  lateral  wall  of  the 
sphenoidal  sinus,  with  meningitis,  erosion  of  the  cavernous  sinus, 
thrombosis  of  the  carotic  sinuses  and  right  petrosal  sinus,  and 
intradural  abscess  in  the  middle  cranial  fossa.  In  Schlagenhaufer's^^ 
case  there  was  softening  of  the  sphenoidal  body,  meningitis,  and 
thrombo-phlebitis  of  the  longitudinal  sinus.  In  Pauncz's^^  case  puru- 
lent thrombo-phlebitis  of  the  circular  sinus  of  Ridlei  and  of  the  inferior 
and  superior  petrosal  sinuses  was  found.  In  Halasz's^-  case,  suppura- 
tion in  the  sphenoidal  sinus  and  encephalitis.  In  Schroeder's^^  case, 
empyema  of  the  sphenoidal  sinuses,  perforation,  meningitis,  and 
thrombo-phlebitis  of  the  cavernous  and  petrosal  sinuses. 

In  multiple  accessory  sinus  suppurations  the  following  conditions 
have  been  reported  :  Weichselbaum^'^  had  a  case  of  suppuration  of  the 
right  maxillary  antrum  and  frontal  sinus,  with  abscess  over  the  upper 
lid,  and  extradural  and  frontal  lobe  abscesses.     Griinwald^^  reported  a 

^  Bull.  Soc.  Anatom.,  Paris,  1895.  -  Lo:.  cit. 

■*  "Die  Lehre  von  den  Naseneitcrungcn,"  1893.       ■*  Tod,  La  Clinigiie,  1900. 

"  Bull.  So'.  Anat.,  1892.  *•  Nasenkrankheiten,  etc.,  1895. 

"^  Prager  Mediz.  Wochenschrift,  1893. 

^  Internat.  Zentralblatt  für  Laryngologie,  Bd.  X. 

"  Berliner  Klinische  Wochenschrift,  1892. 

^'  Wiener  Klinische  Wochenschrift,  1899. 

^^  Zeitschrift  für  Augenheilkunde,  1906.  ^-  Orvosi  Hetilap.,  1904- 

^^  Zeitschrift  für  Ohrenheilkunde,  1906. 

"  Wiener  Medizinische  Wochenschrift,  1890.  ^^  Loc.  cit. 


76  THE  OPTIC  XERVE 

case  of  maxillan'  and  sphenoidal  sinus  suppuration,  with  purulent 
periostitis  and  softening  in  the  posterior  walls  of  both  cavities. 
Pauncz^  reported  a  case  with  suppuration  in  the  maxillary  antrum  and 
ethmoidal  cells  on  the  left  side,  and  perforation  from  the  maxillar\' 
antrum  into  the  orbital  cavit\-,  resulting  in  basilar  meningitis  and  brain 
abscess.  In  Hansberg's-  case,  suppuration  of  the  right  frontal 
sinus  and  of  all  the  ethmoidal  cells  led  to  caries  of  the  ethmoid, 
meningitis,  and  abscess  in  the  left  frontal  lobe  of  the  cerebrum. 
Duplay^  had  a  case  with  exophthalmos  on  the  right  side,  total 
blindness,  and  basal  meningitis,  which  was  chiefly  present  in  the 
sella  turcica.  A  purulent  phlebitis  was  found  in  most  of  the  venous 
sinuses,  and  in  the  orbital  cellular  tissue  there  were  a  number  of 
purulent  areas.  Pus  lav  in  the  sphenoidal  sinuses,  and  in  the  right 
ethmoidal  cells.  In  Russel's  case"*  \-ision  gradually-  diminished,  and 
ptosis  of  the  upper  lid  and  immobility  of  the  e^^e  on  the  left  side 
occurred.  Post-mortem  it  was  found  that  an  intradural  abscess  lay 
in  the  middle  cranial  fossa,  and  that  there  was  an  empyema  both  in 
the  sphenoidal  sinus  and  in  the  right  ethmoidal  cells  ;  the  cavernous 
and  petrosal  sinuses  and  the  left  ophthalmic  veins  were  thrombosed. 
In  \^ossius'^  case,  in  which  suppuration  of  the  sphenoidal  sinuses  and 
the  left  ethmoidal  cells,  as  well  as  caries  of  the  sphenoid,  had 
occurred,  a  thrombo-phlebitis  of  the  superior  ophthalmic,  angular, 
and  left  anterior  facial  veins  set  in,  which  led  to  purulent  pachy-  and 
leptomeningitis.  In  Holmes's^  case  fronto-ethmoidal,  along  with 
sphenoidal  sinus  suppuration,  led  to  diplopia,  double  optic  neuritis, 
and  abscess  in  the  right  frontal  lobe.  In  a  case  of  Demarquay's"^  the 
eye  was  immobile  and  proptosed,  and  insensitive  to  light  on  the  right 
side.  On  post-mortem  examination  the  sphenoidal,  ethmoidal,  and 
maxillarv  sinuses  were  found  filled  \rith  pus,  and  the  cavernous  venous 
sinus  contained  a  purulent  thrombus.  Panse^  reports  a  case  of  frontal, 
ethmoidal,  maxillary,  and  sphenoidal  sinus  suppuration,  in  which  the 
ca\-ities  contained  tuberculous  granulations.  A  neuro-retinitis  was 
present  on  both  sides.  In  the  ethmoid  and  anterior  part  of  the  sphenoid 
tubercular  caries  was  present,  and  both  orbital  roofs  were  carious 
and  were  covered  with  cheesy  material.     Localized  meningitis,  internal 

'   Orvosi  Hetilap. 

^  Zeitschrift  für  Ohrenheilkunde,  Bd.  XLIV. 

^  Arch.  Gc'n.  de  MM.,  1874.  *  Medical  Times  and  Gazette,  1878. 

^  Zeitschrift  für  Augenheilkunde,  1900.  •"  Archives  of  Ophthalmology,  1SS6. 

"  M.  Mackenzie,  "Diseases  of  the  Nose,"  etc.,  1884. 

^  Archiv  für  Laryngologie,  loc.  cit. 


CLINICAL  CONSIDERATIONS  77 

hydrocephalus,  and  caseous  pneumonia,  resulted.  Leber^  leports  a 
case  with  tumour  in  the  nasal  cavities,  empyema  of  the  sphenoidal  sinus, 
and  blindness  due  to  atrophy  of  the  optic  nerves.  Purulent  menin- 
gitis and  thrombo-phlebitis  of  the  cerebral  sinuses  were  found  on  post- 
mortem examination.  Finlag"'  reports  a  case  with  suppuration  of  the 
sphenoidal  sinuses  and  ethmoidal  cells,  in  which  thrombo-phlebitis 
of  the  cavernous  and  circular  sinuses  occurred. 

The  path  of  infection  in  these  cases  may  be  by  direct  continuity, 
by  the  lymphatic  system,  or  by  the  venous  circulation.  That 
the  complications  were  due  to  the  accessorv  sinus  suppuration 
the  post-mortem  examinations  demonstrated.  It  is  possible  that 
intracranial  complications  may  arise  by  infection  of  the  lymphatic 
channels,  and  especially  by  those  that  pass  along  with  the  olfactory 
nerves  through  the  cribriform  plate.  This  has  not  yet  been  proved 
bacteriologically  or  microscopically.  That  such  disease  processes  as 
occur  in  the  accessory  sinuses,  and  their  spread  from  there  to  the 
orbital  contents,  and  to  the  optic  nerve  within  its  canal,  may  be 
intimately  associated  with  the  system  of  veins  is  certain.  Also  the 
intracranial  and  cerebral  complications  stand  closely  related  to  the 
venous  system.  We  may  include  under  the  term  "  circulatory  inter- 
ference "  such  symptoms  as  h3-percTmia,  oedema  of  the  tissues  and  of 
the  optic  nerve  and  its  sheath,  haemorrhages,  emboli,  thrombo-phlebitis, 
and  thrombosis.  Zuckerkandl'^  has  shown  by  his  investigations  that 
the  veins  of  the  nasal  mucous  membrane  anastomose  with  those  of  the 
face. 

The  anterior  ethmoidal  \-eins  communicate  \\ith  the  veins  of  the 
dura  and  pia  mater,  and  the  venous  trunks  that  arise  from  the 
nasal  mucous  membrane  anastomose  with  the  veins  of  the  palate  and 
pharynx  and  with  the  pterygo-palatine  plexus.  The  venous  plexus 
around  the  lachrymal  duct  and  the  lachrymal  sac  opens  into  the  anterior 
facial  vein,  and  is  in  communication  with  the  ophthalmic  and  infra- 
orbital veins.  Zuckerkandl  has  described  a  venous  twig,  the  lachrymo- 
facialis,  which  takes  origin  in  the  anterior  ethmoidal  cells  and  passes 
through  the  lachrymal  bone.  .\  twig  also  brings  the  plexus  in  the 
maxillarv  antrum  into  communication  with  the  vena  ophthalmica 
facialis.  Kuhnt"*  describes  anastomoses  between  the  veins  of  the  dura 
mater  and  those  of  the  frontal  sinus  by  means  of  perforating  veins. 

'"■  Archiv  für  Layyngo.'ogie,  Bd.  XVII. 

^  Monatsschrift  für  Ohrenheilkunde,  1905.  ^  Lac.  cit. 

*    "Entzündliche  Erkrankungen  der  Stirnhöhle,"  1S95. 


jS  THE  OPTIC  XERVE 

Knhnt  and  Gurwitsch^  also  found  communicating  twigs  between  lh(^ 
frontal  sinus  veins  and  the  superior  ophthalmic  and  supra-orbital  veins. 
Into  the  superior  ophthalmic  veins,  too,  enter  the  anterior  and  posterior 
ethmoidal  veins,  while  in  addition  the  anterior  ethmoidal  vein  may 
communicate  with  the  supra-orbital  and  with  the  angular  vein. 
According  to  Onodi,"-  the  vena  ethmoidalis  anterior  mav  take  its 
course  in  a  canal,  the  semicanalis  ethmoidalis,  through  the  frontal 
sinus  and  first  and  second  orbital  cells,  in  which  it  lies  freely  exposed 
for  a  considerable  part  of  its  course.  The  superior  ophthalmic  vein 
is  not  onlv  in  communication  with  the  ethmoidal  veins,  but  also  with 
the  vena  centralis  of  the  retina  and  with  the  inferior  ophthalmic 
vein. 

The  orbital  veins  are  thus  in  communication  with  the  veins  of  the 
face  and  of  the  nasal  cavit\-,  and  with  the  pterygoid  plexus.  They 
emptv  themselves  posteriorly  into  the  cavernous  sinus.  The  veins  of  the 
sphenoidal  sinus  mav  also  anastomose  with  the  orbital  veins  and  with 
the  cavernous  sinus.  Sometimes  the  central  vein  of  the  retina  opens 
direct]}'  into  the  cavernous  sinus,  but  it  mav  also  pass  through  the 
spheno-maxillary  fissure  into  the  ptervgo-palatine  plexus.  The  inferior 
ophthalmic  vein  may  also  communicate  with  the  plexus  in  the 
pterygo-palatine  fossa.  With  so  complex  a  svstem  of  anastomoses  the 
disease  of  nasal  accessory  sinuses,  when  affecting  a  vein,  may  readily 
spread  to  neighbouring  parts. 

Orbital  cellulitis  or  disease  of  the  mucous  membrane  covering  the 
veins  mav  be  the  cause  of  a  thrombo-phlebitis.  Besides  spread  of  the 
infection  bv  direct  extension,  emboli  may  be  set  free  through  softening 
of  the  thrombi.  Pressure  from  orbital  cellulitis  and  from  disease  of 
the  sheath  of  the  optic  nerve  may  produce  congestion  and  cedema. 
In  three  cases  of  maxillarv  antrum  suppuration,  Kuhnt  saw  embolus  oi 
the  central  vein  of  the  retina  occurring.  Operation  was  refused  in 
these  cases.  In  maxillarv  antrum  suppuration,  too,  Fouchet  observed 
a  thrombo-phlebitis  of  the  pterygoid  and  ophthalmic  plexuses.  In 
suppurations  of  the  frontal  sinuses  the  following  observations  have 
been  made.  Zirn  found  a  thrombo-phlebitis  of  the  ophthalmic  veins 
and  of  the  cavernous  sinus.  Bourot-Lecard  observed  a  similar  sequel. 
E.  Fränkel,  Macewen-Millar,  and  Carver,  record  thrombo-phlebitis  in 
the  superior  longitudinal  sinus.  In  sphenoidal  sinus  suppuration, 
Raymond  records  a  case  in  which  thrombosis  of  the  ophthalmic  veins 
and   of  the   cavernous   sinus   occurred.     Ortmann   had   a   case   with 

'  Graefe's  Archiv,  Bd.  XXIX.  -  Archiv  für  Laryngologie,  he.  cit. 


CLINICAL  CONSIDERATIONS  79 

thrombosis  of  both  cavernous  sinuses  ;  Pekastovsky,  a  case  with 
thrombosis  of  the  longitudinal  sinus  ;  Scholz,  a  case  with  thrombosis 
of  the  carotic  and  right  petrosal  sinuses  ;  Schlagenhaufer,  thrombo- 
phlebitis of  the  longitudinal  sinus  ;  Pauncz,  purulent  thrombo-phlebitis 
of  the  sinus  circularis  Ridlei  and  the  inferior  and  superior  petrosal 
sinuses  ;  Schröder,  thrombo-phlebitis  of  the  cavernous  and  petrosal 
sinuses. 

In  cases  with  multiple  accessory  sinus  suppuration  the  following 
observations  have  been  made  :  In  Duplay's  case  ethmoidal  and 
sphenoidal  suppurations  led  to  purulent  thrombo-phlebitis  of  the 
majority  of  the  venous  sinuses  within  the  cranium.  In  Russel's  case, 
also  with  ethmoidal  and  sphenoidal  disease,  the  cavernous  and  petrosal 
sinuses  were  thrombosed,  as  well  as  the  ophthalmic  veins  on  the  left  side. 
In  Vossius'  case,  with  disease  of  the  ethmoidal  and  sphenoidal  sinuses, 
thrombo-phlebitis  of  the  superior  ophthalmic,  angular,  and  left  facial 
veins  occurred.  Finlag,  in  a  case  of  ethmoidal  and  sphenoidal  sup- 
puration, reports  thrombo-phlebitis  of  the  cavernous  and  circular 
sinuses. 

Dehiscences  in  the  bone  walls  of  the  accessorv  sinuses  have  an 
important  bearing  on  the  spread  of  the  disease  from  any  such  sinus. 
Such  defects  in  the  bone  may  be  congenital  or  due  to  senile  atrophy. 
By  the  presence  of  such  defects  the  mucous  membrane  of  the  frontal 
and  maxillary  sinuses  may  touch  the  periosteum  of  the  external  surface 
of  the  frontal  and  maxillary  bones,  and  the  periosteum  of  the  orbital 
cavity.  The  mucous  membrane  of  the  frontal  and  sphenoidal  sinuses 
may  in  this  manner,  too,  be  in  touch  with  the  dura  mater.  The 
membrane  lining  the  semicanalis  ethmoidalis  may  bring  the  mucous 
membrane  of  the  frontal  sinus  and  orbital  cells  into  comnumication 
with  the  orbital  periosteum  externally  and  with  the  dura  mater 
internally.  Dehiscences  in  the  walls  of  the  optic  canal,  and  of  the 
ethmoidal  and  sphenoidal  sinuses,  may  bring  the  mucous  membrane 
lining  the  sinuses  into  touch  with  the  sheath  of  the  optic  nerve. 
A  defect  in  the  lamina  papyracea  will  bring  the  mucous  membrane 
of  the  ethmoidal  cells  into  touch  with  the  periosteum  of  the 
orbit. 

Zuckerkandl  and  I  have  observed  extreme  thinning  of  the  walls  of 
the  maxillary  antrum,  with  smaller  or  larger  defects  in  parts,  that  have 
resulted  from  senile  atrophy.  In  one  of  Zuckerkandl 's  cases  the  frontal 
sinus  communicated  with  the  cranial  cavity,  and  in  Merlin's  case  the 
frontal  sinus  comnumicated  with  the  orbital  cavity.     Periostitis,  peri- 


8o  THE  OPTIC  XERVE 

neuritis  optica,  neuritis,  and  optic  atrophy,  and  other  sequelae,  may 
easily  occur  in  such  cases  as  have  defects  in  the  optic  canal  ;  and 
in  defects  of  the  cranial  floor,  pachymeningitis,  extradural  abscess,  and 
cerebral  abscess,  may  result.  Bone  defects  between  the  accessory 
sinuses  and  the  face, and  pterygo-palatine  fossa,  may  produce  periostitis, 
cellulitis,  thrombo-phlebitis,  and  abscesses. 

Similar  processes  mav  ensue  where  a  defect  involves  the  walls  of 
the  orbital  cavitv,  and  in  addition  emphysema  may  result.  Such 
unfavourable  complications  occur,  as  a  rule,  without  the  presence 
of  bone  defects.  Periostitis  and  osteitis,  leading  to  caries  and  necrosis, 
with  perforations,  occur.  In  such  a  sequence  the  neighbouring  soft 
tissues  mav  be  attacked.  The  involvement  of  the  veins  in  conjunction 
with  or  apart  from  such  direct  extension  of  the  disease  has  already 
been  considered.  In  this  extension  of  disease  from  suppurating 
accessory  sinuses,  the  optic  nerve  may  be  affected  by  direct  involve- 
ment of  the  optic  canal  and  the  optic  sheath,  or  by  a  periostitis  which 
extends  from  the  orbital  cavitv.  The  nerve  may  also  be  affected  by 
direct  pressure,  or  pressure  on  its  nutrient  arteries  caused  by  orbital 
cellulitis,  or  it  may  be  diseased  secondarily  to  a  thrombo-phlebitis  of 
the  ophthalmic  veins. 

Further,  it  must  be  remembered  that  one  suppurating  accessory 
sinus  often  directly  affects  another.  Thus  frontal  sinus  disease 
may  extend  to  the  orbital  cells  of  the  ethmoid,  and  so  to  the  other 
ethmoidal  cells.  A  communication  may  exist  congenitalh'  in  the 
septum  separating  the  two  frontal  sinuses,  or  such  a  communication 
may  be  due  to  perforation  caused  by  inflammation.  Such  an  inter- 
communication ma}'  also  occur  between  the  sphenoidal  sinuses  as  a 
result  of  disease.  Similarly,  any  of  the  thin  septa  that  may  lie  between 
different  sinuses  are  liable  to  perforation  as  a  result  of  suppurative 
osteitis,  caries,  and  necrosis.  In  this  manner  neighbouring  sinuses  are 
involved.  Thus  the  maxillary  antrum  may  infect  the  ethmoidal  cells, 
and  these  the  sphenoidal  sinus,  or  else  from  the  frontal  sinus  the 
advance  ma}^  be  in  the  direction  of  the  ethmoidal  cells  and 
sphenoidal  sinuses,  or  it  may  be  in  the  reverse  direction. 

Besides  the  complications  and  symptoms  already  mentioned,  it  will 
be  well  to  summarize  such  s\'mptoms  as  have  been  recorded  in  accessory 
sinus  disease.  Taking  the  maxillary  antrum  first,  we  must  mention  as 
symptoms  lachrymation,  blepharospasm,  and  such  reflex  neuroses  as 
asthma  and  angina  pectoris,  purulent  dacryocystitis,  and  lachrymal 
fistula. 


CLINICAL  CONSIDERATIONS  8i 

Nolthenius^  records  a  case  of  rupture  into  the  nasal  tear  duct  of  a 
suppurating  maxillary  antrum,  and  Treitel-  mentions  in  disease  of  the 
same  sinus  the  formation  of  granulation  tissue  and  a  sequestrum 
which  led  to  dacryocystitis  and  the  formation  of  a  lachrymal  fistula. 
Asthenopia  has  been  recorded  by  Griinwald'^  and  Caldwell,^  and 
others. 

Ziem  and  Fromaget  state  that  after  operating  on  a  diseased 
maxillary  antrum  an  iritis  healed,  and  Kuhnt  describes  improvement 
of  an  iritis  under  similar  conditions.  Ziem  and  Kuhnt  also  saw 
improvement  in  visual  power  in  cases  of  cataract  in  which  the  maxillary 
antrum  disease  had  been  treated.  Kuhnt  also  observed  a  neuro- 
retinitis  resolve  under  such  treatment. 

Grossmann^  records  hyperaemia  of  the  optic  disc,  and  Depaques^ 
observed  blurring  of  the  edges  of  the  optic  disc,  with  diminution  of 
visual  power,  due  to  maxillary  antrum  suppuration.  Courtaix  and 
Kolarowitsch'  report  amblyopia  and  amaurosis  of  dental  origin. 

As  a  result  of  oedema  of  the  retrobulbar  cellular  tissue,  exophthalmos, 
visual  disturbance,  and  even  blindness,  due  to  direct  pressure  and  to 
pressure  on  the  bloodvessels  of  the  optic  nerve,  may  occur.  Körner,* 
Le  Fort,^  and  Pagenstecher, ^"^  record  exophthalmos.  Passing  ambly- 
opia or  amaurosis  has  been  observed  by  Brück, ^^  Pasquier,^-  Buzer,^^ 
Galezowski,^^  and  Önodi.^^  Grünwald^^  and  Panzer^'^  have,  as  a  result 
of  perforation  of  the  wall  of  the  maxillary  antrum,  seen  an  abscess  and 
fistula  in  the  hard  palate.  Tedenat^*  and  Westermayer^^  have  seen 
cases  with  phlegmon  of  the  pterygo-palatine  fossa.  Bournonville,'^ 
Jansen,-'^.  F]atau,^^  and  Lichtwitz, -^  have  described  cases  in  which 
rupture  occurred  through  the  wall  of  the  inferior  meatus,  and  Killian-^ 

^  Monatsschrift  für  Ohrenheilkunde,  1895. 

^   Verhandlungen  der  Laryngologischen  Gesellschaft,  Berlin,  1900. 

^  Loc.  cit.  •'  Medical  Journal  of  New  York,  1898. 

^  Weinlechner,  Bericht  der  k.  k.  Krankenanstalt  Rudolfstift.,  1875. 

®  Bull,  de  la  Soc.  d'Ophth.  de  Paris.  1893.  "^  Loc.  cit. 

^    Verhandlungen  der  Deutschen  Odontologischen  Gesellschaft,  Bd.  VII. 

^  France  Med.,  1876.  ^^  Archiv  für  Augenheilkunde,  1884. 

^^   Wochenschrift  für  die  Gesamte  Heilkunde,  Berlin,  185 1. 

^^  Lanc.  Franc.,  1839.  '•'  Berliner  Klinische  Wochenschrift.  1868. 

^*  Archives  Intern,  de  Larnyg.,  1905. 
^^  Revue  Hebdomadaire  de  Laryng.,  etc.,  1905. 
^^   "  Lehre  von  der  Naseneitcrung,"  2  Aufl. 
"   Wiener  Klinische  Wochenschrift,  1896. 
^^  Soleville,  These  de  Montpelier,  1890. 
^^  Münchener  Medizinische  Wochenschrift,  1895. 

^°  Zentralblatt  für  Chirurgie,  1885.  -'■  Archiv  für  Laryngologie,  Bd.  L 

^^  Rev.  Int.  de  Rhin.,  1893.  -■'  Annal.  de  Malad.  d'Or.,  1896. 

^*  Heymann' s  Handbuch,  Bd.  III. 

5 


82  THE  OPTIC  XERVE 

records  a  case  of  perforation  through  the  middle  meatus.  Dmo- 
chowski^  saw  a  case  in  which  a  suppurating  maxillary  antrum  ruptured 
into  the  sphenoidal  sinus.  Baub\-,-  Dmochowski,^  Kuhnt,-^  Salva,^ 
and  Fischer,^  report  cases  in  which  rupture  occurred  into  the  orbital 
cavity.  Orbital  cellulitis,  orbital  abscesses,  and  thrombo-phlebitis  with 
intracranial  complications  ma}^  as  already  mentioned,  also  occur  in 
similar  cases. 

In  frontal  sinus  suppuration,  reflex  neuroses,  such  as  bulbar  and 
periorbital  neuralgias,  have  been  observed,  and  but  rarely  dacryo- 
cystitis. Kuhnt  and  Lichtwitz  have  described  hypera^mia  of  the  optic 
disc,  with  fulness  of  the  retinal  veins,  and  a  retinal  infiltration  around 
the  disc  ;  and  Kuhnt,  Onodi,  and  others,  have  seen  cases  with  exoph- 
thalmos and  diplopia.  Schmiegelow"  and  Jacqueau^  have  observed 
exophthalmos  of  rapid  onset.  Kuhnt  has  also  noticed  a  haziness 
in  the  lens.  Lapersonne^  has  observed  transitor}^  or  permanent  pareses 
of  the  nerves  of  the  ocular  muscles. 

Periostitis,  perforation  of  the  walls  of  the  frontal  sinus,  oedema  of 
the  retrobulbar  tissue,  orbital  cellulitis,  and  abscess — these  have  been 
frequently  recorded.  Bourot,  Lecard,  Carver,  and  Schröder,  have  seen 
subperiosteal  abscess  on  the  orbital  roof,  and  also  caries  and  necrosis. 
Spencer  Watson^"  removed  two  sequestra,  and  Panas^^  one,  from  the 
orbital  plate  of  the  frontal  bone.  Bäumler,^-  Steinthal, ^^  Köhler,^"' 
Roth,  and  Macewen-Millar,  have  observed  periostitis  of  the  anterior 
wall  of  the  frontal  sinus,  cellulitis  of  the  forehead  and  upper  lid,  and 
abscess  formation  in  these  parts  ;  and  Bote^-^^  had  a  case  in  which  a 
perforation  of  the  anterior  wall  of  the  sinus  occurred.  The  anterior 
wall  is  less  liable  to  disease  than  the  inferior  wall.  Cases  have 
already  been  referred  to  in  which  the  posterior  wall  of  the  frontal 
sinus  was  perforated,  and  others  in  which  orbital  abscess,  thrombo- 
phlebitis, intracranial  and  cerebral  complications,  occurred. 

Burger,^*'' Caldwell ,^"  Hajek.^*  and  Grünwald, ^'-^  have  seen  cases  with 

^  Archiv  fiiy  Laryngologie,  Bd.  III.  -  Arch.  d'Ophthalm.,  1897. 

^  Loc.  cit.  *  Loc.  cit.  ^   Thhe  de  Paris,  1895. 

^  Salva,  loc.  cit.  ^  Archiv  für  Laryngologie,  Bd.  XV. 

^  Internationales  Zentralblatt  für  Laryngologie,  Bd.  X\'I. 

^  Bull,  de  la  Societe  Franc,  d' Ophthal.,  1902. 
^^   "  Diseases  of  the  Nose  and  its  Accessory  Cavities." 

^^  Progrcs  Mid.,  1887.  ^'-  Kongress  für  Innere  Medizin,  1890 

^•'  Medizin.  Korrespondenzblatt  der  Württembergischen  Ärztlichen  Landesvereinc, 
1891. 

^*  Charite-Annal.,  1891.  '"'  Revue  de  Laryng.,  1897. 

^^  Zentralblatt  für  Laryngologie,  Bd.  XI.  ^'  Ibid.,  Bd.  X. 

^^   "Erkrankungen  der  Nasenhöhlen  der  Nase,"  1903.  ^^  Loc,  cit. 


CLINICAL  CONSIDERATIONS  83 

asthenopia,  due  to  ethmoidal  suppuration.  Such  conditions  as  retro- 
bulbar neuritis  and  choked  disc  will  be  referred  to  later.  Purulent 
dacryocystitis  is  a  recognized  complication  of  ethmoidal  suppuration. 
The  eye  may  be  pushed  aside  by  a  mucocele  of  the  ethmoidal  cells  or 
by  an  empyema. 

Hjorty  and  Onodi^  observed  exophthalmos  in  cases  of  ethmoidal 
mucocele  without  disturbance  of  vision.  Baurowitz-'^  has  seen  dip- 
lopia with  exophthalmos  in  such  cases,  and  Mann'*  has  observed  optic 
neuritis  and  exophthalmos.  Riebet^  has  seen  a  similar  case  leading 
to  blindness.  In  a  patient  of  Schmiegelow^  the  mucocele  pushing 
the  eye  aside  contained  sero-purulent  fluid.  Eversbusch"^  has  observed 
a  case  of  ethmoidal  mucocele  in  which  the  exophthalmos  was 
intermittent.  Those  complications  that  lead  to  perforation  of  the 
orbital  plate  of  the  ethmoid  and  produce  orbital  cellulitis  have  already 
been  referred  to,  and  also  such  as  lead  to  intracranial  complications. 

Baumgarten**  observed  the  presence  of  oculo-motor  paresis  in 
a  case  of  sphenoidal  suppuration,  and  Post^  has  seen  incurable 
blindness  and  exophthalmos  as  a  result  of  necrosis  of  the  small  wing 
of  the  sphenoid.  In  other  respects  the  patient  had  been  cured. 
Orbital  cellulitis  may  also  occur  in  cases  of  sphenoidal  suppuration. 
The  cases  that  pass  on  to  intracranial  infection  have  already  been 
referred  to.  Choked  disc,  retrobulbar  neuritis,  and  optic  atroph\',  will 
be  discussed  later  in  detail  as  complications  of  sphenoidal  suppuration. 

In  a  case  recorded  by  Sokos  and  Luc,^*^  maxillary  and  frontal  sinus 
suppuration  was  associated  with  diplopia,  and  in  a  case  of  maxillary 
and  sphenoidal  sinus  suppuration  Lapersonne^^  observed  total  paralysis 
of  the  oculo-motor  nerve.  Ingersoll  described  a  case  of  frontal  sinus 
and  ethmoidal  cell  suppuration,  in  which  exophthalmos  was  present  ; 
and  in  a  similar  case  Broeckart^^  observed  vitreous  haziness,  with 
detachment  of  the  retina.  Hoffmann^^  in  one  case  found  rupture 
into  the  orbital  cavity,  and  an  orbital  abscess,  associated  with  frontal, 
ethmoidal,  and  sphenoidal  sinus  suppuration;  and  in  another  case  of 
ethmoidal  and  sphenoidal  suppuration  he  observed  exophthalmos  and 
diplopia. 

^  Schmiegelow,  Archiv  für  Laryngologie,  Bd.  XV. 

^  Archiv  für  Laryngologie,  Bd.  XVII.  ^  Ibid.,  Bd.  XII. 

*    Verhandlungen  der  Deutschen  Otologischen  Gesellschaft,  1901. 

^  Kuhnt,  loc.  cit.  ^  Archiv  für  Laryngologie.  Bd.  XV. 

'''   "  Gracfe-Sämisch'  Handbuch,"  2  Aufl.  ^  Orvosi  Hetilap,  1903. 

^  Lancet,  1882.  ^°  Revue  de  Laryngol.,  189g.  "  Loc.  cit. 

^"  Revue  de  Laryngol.,  1901. 

^^  Zeitschrift  für  Augenheilkunde,  1906. 

5—3 


84  THE  OPTIC  NERVE 

F.  R.  Alexander^  has  seen  a  case  in  which  a  metastatic  abscess  in  the 
vitreous  of  one  eye  was  associated  with  suppuration  in  the  maxillary 
antrum  and  ethmoidal  cells. 

I  proceed  next  to  the  subject  of  neuritis  of  the  optic  nerve  trunk 
within  its  canal,  and  of  optic  atrophy.  As  has  already  been  pointed 
out,  inflammatory  disease  of  the  orbital  tissues  may  spread  directly 
to  the  optic  nerve.  This,  and  also  pressure  on  that  portion  of  the 
optic  nerve  that  is  free  from  bloodvessels,  as  well  as  pressure  on  its 
nutrient  bloodvessels,  may  lead  to  visual  disturbances  and  to  blindness. 
In  a  similar  wav  disease  of  those  nasal  accessory  sinuses  which  are  in 
close  proximitv  to  the  nerve  may  extend  through  the  optic  canal  to 
the  sheath  of  the  optic  nerve.  Any  bone  defect  in  intervening  septa 
between  such  sinuses  and  the  optic  nerve  will  favour  such  a  direct 
extension  of  the  inflammation. 

Direct  infection  through  intervening  bone  is  by  osteitis  and 
periostitis,  though  it  may  also  be  by  venous  thrombosis.  Duplay, 
Horner,  Panas.  Rouge,  Rüssel,  Ra\miond,  Demarquay,  Vossius,  Holmes, 
and  others,  have  observed  cases  in  which  visual  disturbance  or  blind- 
ness was  associated  with  disease  of  nasal  accessor}'  sinuses,  and  in 
which  the  diagnosis  was  confirmed  by  post-mortem  examination. 
Although  in  some  cases  optic  atrophy  had  already  occurred,  3'et  in 
others  treatment  of  the  diseased  nasal  sinuses  led  to  improvement,  and 
even  cure,  of  the  optic  condition.  On  the  other  hand,  in  similar  cases 
of  associated  visual  disturbance  and  sinus  disease,  treatment  of  the 
sinuses  at  fault  led  to  no  improvement  of  the  optic  disease. 

Our  knowledge  of  the  path  of  infection,  and  of  the  optic  nerve,  its 
sheath  and  bloodvessels,  are  as  yet  insufficient.  We  are  also  still  in 
want  of  detailed  records  of  the  anatomical  relations  of  the  accessorv 
sinuses  to  the  optic  nerve  in  these  cases. 

Even  in  cases  of  caries  and  necrosis  of  the  sphenoidal  sinus  walls 
there  mav  be  no  optic  neuritis.  Berger  and  Tyrmann-  have  recorded 
a  case  of  gradual  separation  of  a  sequestrum  from  the  body  of  the 
sphenoid  which  finallv  led  to  meningitis  without  producing  at  any 
time  signs  of  visual  disturbance.  Baratoux^  describes  a  case  in 
which  a  sequestrum  separated  from  the  sphenoid,  and  was  removed 
through  the  nose  without  causing  any  complications. 

Hajek^  has  observed  extensive  destruction  of  the  anterior  wall 
of  the  sphenoid  produced  by  s\'philis,  which  caused  no  exceptional 

^    Verhandlungen  der  Deutschen  Otologischen  Gesellschaft,  1905.  -  Loc.  cit. 

^  Arch.  Ital.  di  Laryng.,  18S3.  *  Loc.  cit. 


CLINICAL  COXSIDERATIOXS  85 

symptoms.  Flatau^  records  twenty-six  cases  of  sphenoidal  sinus  sup- 
puration with  caries,  yet  showing  no  symptoms  of  ocular  disturb- 
ance. Foucher^  describes  necrosis  of  turbinated  bones  and  of  the  wall 
of  the  sphenoidal  cavity  in  the  case  of  a  girl  fifteen  years  of  age,  in 
whom  mercury  as  an  antisyphilitic  remedy  was  given.  Sequestra 
finally  separated,  and  the  child  died.  At  no  time  were  visual 
disturbances  detected. 

Schäffer,^  Önodi,^  Schmiegelow,^  and  Hoffmann,®  also  state  that 
in  numerous  cases  of  sphenoidal  suppuration  no  changes  in  the  visual 
power  can  be  detected.  Kinkel"  treated  twenty  cases  of  sphenoidal 
suppuration  without  finding  anything  abnormal  in  the  visual  fields 
or  in  the  ocular  fundi.  Contrary  to  the  findings  of  Grünwald,* 
Ziem,^  Berger,^°  Kuhnt,^^  and  Bryan, ^-  Henrici  and  Häffner,^^in  thirty- 
six  cases  of  accessory  sinus  disease,  found  a  normal  visual  field.  These 
facts  are  to  be  explained,  and  in  this  Hoffmann^"*  agrees,  by  the  varying 
relation  of  accessory  sinuses  and  optic  nerves,  as  already  described. 
There  are  two  factors  that  help  in  the  limitation  of  accessory  sinus 
disease,  and  prevent  it  from  spreading  to  the  optic  nerves  :  the  nerves 
may  come  into  no  relation  with  the  sphenoidal  sinuses  or  ethmoidal  cells, 
and  the  wall  of  the  sphenoid  may  be  very  thick.  The  variation  in 
thickness  ranges  between  i  millimetre  and  12  millimetres. 

It  is  evident  that  even  destruction  of  bone  may  occur  in  accessory 
sinuses,  and  yet  no  visual  disturbance  result. 

In  considering  optic  neuritis,  we  must  limit  ourselves  to  its  associa- 
tion with  accessory  sinus  disease.  It  is  necessary  to  point  out  that 
the  stereotyped  explanation  that  such  an  optic  neuritis  is  due 
only  to  sphenoidal  sinus  suppuration  cannot  be  maintained.  As  I 
have  already  pointed  out^^,  the  optic  nerves  may  be  in  close  proximity 
to  the  ethmoidal  cells,  and  yet  be  in  no  relation  to  the  sphenoidal 
sinuses.  Schmiegelow,^^  Alexander,^^  and  Hoffmann, ^^  have  already 
taken  cognizance  of  this  fact,  and  with  regard  to  that  part  of  the  nerve 
which  lies  in  the  optic  canal  Pauncz  ^  accepts  the  same  view  ;  but  he 

^  Zentnilblatt  für  Laryngologie,  1894-1895.  "  Ibid. 

^  Deutsche  Medizinische  Wochenschrift,  1892. 

*  Archiv  für  Laryngologie,  loc.  cit.  "  Lac.  eil.  ^  Lac.  cit. 

''  American  Laryng.  Assoc,  1902.  ^  Lac.  cit. 

®  Berliner  Klinische  Wochenschrift,  1888. 

^°   "  Rapports  entre  les  Malad,  des  Yeux,"  etc.,  1892.  "  Loc.  cit. 

^^  American  Laryng.  Assoc,  1895. 

^^  Münchener  Medizinische  Wochenschrift,  1904.  "  Loc.  cit. 

^^  Zeitschrift  für  Aiigenheilkitnde,  loc.  cit.  ;  Archiv  für  Laryngologie,  loc.  cit. 
^^  Loc.  cit.  ^^  Loc.  cit.  ^''  Loc.  cit. 

^^  Archiv  für  Augenheilkunde,  Bd.  LH. 


86  THE  OPTIC  XERVE 

holds  that  the  intracranial  portion  of  the  nerve  which  lies  between 
chiasma  and  optic  canal  lies  in  close  relation  solely  with  the  sphenoidal 
cav-ity,  and  from  that  it  is  separated  by  thick  bone.  These  two 
statements  can  be  controverted  bv  the  anatomical  relations  already 
detailed.  Where  \-isual  disturbance  is  associated  with  suppuration 
both  in  sphenoidal  sinuses  and  ethmoidal  cells,  we  are  not  correct 
in  taking  into  consideration  only  the  sphenoidal  sinus  suppuration. 
Schmiegelow^  takes  up  the  right  attitude  in  considering  both  the 
ethmoidal  and  sphenoidal  suppuration  as  factors,  without  discrimi- 
nating between  them.  Halstead-  and  PoUatschek^  have  in  cases  of 
sphenoidal  and  ethmoidal  suppuration,  associated  with  \-isual  dis- 
turbance, considered  only  the  sphenoidal  suppuration  as  a  causal 
factor,  without  gi\*ing  am*  reason  for  excluding  from  consideration 
the  disease  in  the  ethmoidal  cells. 

Spreading  of  the  disease,  whether  by  direct  extension  or  through 
affection  of  bloodvessels,  is  just  as  possible  from  the  posterior 
ethmoidal  cells  as  from  the  sphenoidal  sinuses. 

Mendel^  and  Lapersonne^  state  that  a  one-sided  optic  neuritis, 
broadl}-  speaking,  is  referable  to  intranasal  disease.  ^lendel  found 
that  in  about  one-half  of  the  cases  of  unilateral  optic  neuritis  this 
relation  to  intranasal  trouble  could  be  made  out.  As  double  optic 
neuritis  is  characteristic  of  intracranial  trouble,  so  unilateral  optic 
neuritis,  he  says,  is  characteristic  of  orbital  disease.  Optic  neuritis, 
he  says,  is  rarely  caused  b}-  frontal  sinus  disease,  more  often  b}' 
maxillar\-  and  ethmoidal  disease,  but  chiefly  by  sphenoidal  disease. 
The  main  characteristic  of  an  optic  neuritis  purely  of  accessory  sinus 
origin  is  that  it  is  unilateral.  Although,  strictly  speaking,  it  is  possible 
for  both  optic  nerves  to  be  affected  in  their  canals  by  double  sphenoidal 
suppuration,  yet  a  double  oedematous  neuritis  should  specialh*  make 
us  suspect  an  intracranial  process. 

Professor  H.  Sattler,^  on  being  approached  bv  me  on  this  subject, 
answered  that  unilateral  optic  neuritis,  and  also  optic  atrophy,  are 
by  no  means  characteristic  of  disease  of  the  sphenoidal  sinuses  or 
ethmoidal  cells  alone.  Inflammations,  haemorrhages,  or  tumours,  at 
the  cerebral  end  of  the  optic  canal,  or  toxic  agents,  may  similarh'  cause 
a  unilateral  neuritis.  The  rule  laid  down  by  ^lendel  and  Lapersonne 
cannot  be  maintained,  for  against  its  application  is  ever\'  case  in  which 

^  Loc.  cit.  -  American  Lan-ng..  Rhin.,  and  Otol.  Society-,  190 1. 

^  Zentralblatt  für  Laryngologie.  Bd.  XXII. 

*  Zeutralblatt  für  A  iigenheilkimde . 

"  Loc.  cit.  ^  Önodi,  Archiv  für  Laryngologie,  Bd.  XVI. 


CLINICAL  CONSIDERATIONS  87 

double  visual  disturbance  occurs  associated  with  unilateral  sinus  sup- 
puration. And  such  a  double  affection  arising  from  disease  of  the 
posterior  ethmoidal  cell  or  sphenoidal  sinus  of  one  side  is  possible,  as 
can  be  proved  by  the  morphological  observations  already  indicated 
by  me.  In  this  Mendel  and  Lapersonne  can  be  supported — that  the 
majority  of  visual  disturbances  caused  by  accessory  sinus  disease  have 
been  unilateral. 

Less  in  number  are  the  cases  of  bilateral  sinus  suppuration 
associated  with  double  optic  neuritis,  and  rarer  still  cases  of  double 
optic  neuritis  caused  by  unilateral  sinus  suppuration,  or  a  contra- 
lateral optic  neuritis  caused  bv  one-sided  sinus  suppuration.  As  an 
^etiological  factor  must  not  be  forgotten  those  cases  of  visual  dis- 
turbance caused  by  operative  procedure  on  the  accessory  sinuses. 

This  occurred  in  a  case  observed  by  Hirschberg. ^  An  operation 
was  carried  out  through  the  maxillary  antrum  in  order  to  open  up  the 
ethmoidal  and  sphenoidal  sinuses  on  the  right  side,  on  account  of 
suppuration  in  all  these  sinuses.  After  the  operation  the  upper  half 
of  the  pupil  showed  insufficiency  of  action.  This  must  have  been 
caused  by  a  lesion  of  the  optic  nerve. 

As  has  already  been  noted — and  a  glance  at  Figures  9,  10,  and  31, 
will  recall  it — the  optic  nerve  may  for  a  varying  distance  run  in  the 
wall  of  the  sphenoidal  sinus  or  posterior  ethmoidal  cell. 

Of  cases  of  sinus  suppuration  on  one  side  causing  visual  dis- 
turbance or  blindness  on  that  side,  w'e  have  already  mentioned  the 
records  of  Duplay,  Horner,  Panas,  Rouge,  Rüssel,  Raymond,  Demar- 
quay,  Leber,  and  Holmes.  Berger^  records  two  cases  of  optic  neuritis 
that  ended  in  amaurosis.  Grossmann^  assumes  that  the  association 
between  disease  of  the  sphenoidal  sinus  and  visual  disturbance  in  four 
of  his  cases  was  a  causal  and  not  an  accidental  one.  Snellen,"^  in  two 
cases  of  optic  atrophy,  ascribes  the  change  to  sphenoidal  suppuration, 
and  Knappt  refers  optic  disc  changes  in  one  case  to  disease  of 
the  sphenoidal  sinus.  Hirschmann  believes  the  cause  of  a  temporal 
hemianopsia,  atrophic  changes  in  the  temporal  half  of  the  left  disc,  and 
pallor  of  the  similar  part  of  the  right  disc,  in  a  case  of  his,  to  have  been 
either  suppuration  in  the  sphenoidal  sinuses  or  a  tumour  in  the  region 
of  the  sella  turcica.  This  case  was  not  operated  upon,  and  did  not 
come  to  post-mortem  examination. 

In  the  above  cases  more  detailed  information  is  lacking. 

^   Zentralblatt  für  Augenheilkunde.  ~  Loc.  cit. 

^  Allgemeine  Wiener  Medizinische  Zeitung,  1893. 

■*  Ned.  Tijdschr.  vor  Geneesk.,  1894.  ^  Zeitschrift  für  Ohrenheilkunde,  1894. 


88  THE  OPTIC  NERVE 

Lapersonne^  reports  three  cases  in  which  operation  on  diseased 
sinuses  had  no  influence  on  the  course  of  associated  optic  neuritis. 
Grönbäk-  reports  a  case  of  amaurosis  associated  with  ethmoidal  sup- 
puration, in  which  operation  on  the  sinuses  had  no  influence  on  the 
blindness.  Post^  records  a  case  with  necrosis  of  the  small  wing  of  the 
sphenoid,  in  which  exophthalmos  and  amaurosis  were  present.  On 
removal  of  the  sequestrum,  the  exophthalmos  disappeared,  but  the 
amaurosis  remained.  Risley"*  reports  a  case  of  ethmoidal  and 
sphenoidal  suppuration  in  which  the  eye  became  blind. 

Cases  are  on  record  in  which  a  one-sided  disturbance  of  vision 
associated  with  accessory  sinus  disease  got  well,  sometimes  as  a  result 
of  treatment,  and  sometimes  without  it. 

Coppez  and  Lor^  report  a  case  of  sphenoidal  sinus  suppuration  in 
which  an  associated  one-sided  optic  neuritis  healed  spontaneously,  not- 
withstanding the  refusal  of  all  surgical  interference .  Mendel  also  remarks 
that  retrobulbar  optic  neuritis  may  get  well  spontaneously,  or  after 
very  simple  means  of  treatment.  Coppez's®  case  had  suppuration  of  the 
sphenoidal  sinus,  with  the  presence  of  a  sequestrum  i  centimetre  long. 
The  eyeball  was  turned  outwards  and  a  very  little  forwards  ;  the  left 
optic  disc  was  blurred,  and  vision  was  defective.  The  case  was  cured. 
Mendel'  reports  a  case  of  one-sided  retrobulbar  optic  neuritis  which 
improved  very  much  in  vision  after  opening  up  diseased  ethmoidal 
cells.  Bergmeister  and  Hajek^  report  a  case  of  cure  of  a  one-sided 
choked  disc  after  treatment  of  ethmoidal  suppuration.  Fliess^  saw 
some  benefit  result  from  treatment  in  a  case  of  right-sided  sphenoidal 
sinus  suppuration  associated  with  retrobulbar  neuritis.  In  Lor's^° 
case  of  sphenoidal  sinus  suppuration  associated  with  optic  neuritis  and 
symptoms  of  sudden  blindness,  operation  resulted  in  a  cure  of  the  eye 
condition.  NueP^  reports  three  cases  similar  to  this  one.  Either 
neuritis  or  neuro-retinitis  was  present.  Hoffmann^-  reports  such  a 
case,  associated  with  sphenoidal  and  ethmoidal  suppuration,  in  which 
treatment  was  followed  by  successful  results.     Holmes^^  cured  a  case 

^  Loc.  cit. 

^  Verhandlungen  des  Danischen  Oto-Laryngologischeti  Vereines,  1904. 

^  Loc.  cit. 

■•  Internationales  Zentralblatt  für  Laryngologie,  1905. 

•''  La  Presse  Med.  Beige,  1900.  ^  Ophthalmolog.  Klinik,  1902. 

'  Loc.  cit. 

^  Hajek,  "Die  Erkrankungen  der  Xebcnhiihlcn  der  Nase,"  1903. 

^  Wiener  Klinische  Rundschau,  1895. 

^°  Schmiegelow,  Archiv  fiir  Laryngologie,  Bd.  X\'.  ^^   Ibid. 

^~  Verhandlungen  der  Deutschen  Otologischen  Gesellscliaft,  1897. 

^^  Archives  of  Ophthalmology,  1896. 


CLINICAL  COXSIDERATIOXS  89 

of  visual  defect  of  the  left  eye  by  treating  a  left-sided  sphenoidal  sup- 
puration by  operative  means.  Pauncz^  had  a  case  in  which,  on 
opening  up  and  cleansing  suppurating  ethmoidal  cells,  marked 
amelioration  of  an  optic  neuritis  occurred.  Schmiegelow^  also 
obtained  much  improvement  in  the  visual  power  of  a  patient  by 
operating  on  a  sphenoidal  and  posterior  ethmoidal  suppuration  that 
w'as  associated  with  it.  In  a  case  reported  by  Fuchs  and  Hajek""^  a 
retrobulbar  neuritis  with  central  scotoma  was  cured  after  removing 
polypoid  degenerated  mucous  membrane  from  the  left  ethmoidal  cells 
and  sphenoidal  sinuses. 

Only  a  few  cases  are  on  record  in  which  a  double-sided  accessory 
sinus  suppuration  was  associated  with  double  optic  neuritis.  Mendel"* 
cites  from  an  English  source  a  case  of  double  visual  disturbance,  the 
cause  of  which  lay  in  suppuration  of  the  ethmoidal  cells.  A  case 
of  double  optic  atrophy  occurred  in  my  practice  associated  with 
multiple  sinus  suppuration.  Pollatschek^  accounts  for  bilateral 
amaurosis  in  a  case  of  his  by  the  presence  of  sphenoidal  sinus  suppura- 
tion— a  view  supported  by  me  in  the  discussion*^  that  followed. 
F.  R.  Alexander"  reports  a  case  of  double  optic  neuritis  in  which,  after 
the  opening  up  of  suppurating  ethmoidal  cells  on  the  right  side,  and  a 
suppurating  sphenoidal  sinus  on  the  left  side,  a  cure  was  obtained. 
Schmiegelow^  saw  marked  improvement  in  a  case  of  double  optic 
neuritis  after  operating  on  associated  suppuration  of  the  ethmoidal 
and  sphenoidal  sinuses  of  both  sides.  Delneuville®  treated  a  case  of 
sphenoidal  suppuration,  in  which  visual  disturbance  was  present  on 
both  sides,  by  means  of  irrigation  of  the  sinuses.  After  a  month  of 
such  treatment  the  eye  condition  was  cured. 

These  various  observations  can  be  explained  if  we  consider  the 
close  relation  of  the  optic  chiasma  and  optic  nerve  to  the  sphenoidal 
sinus  and  most  posterior  ethmoidal  cell.  The  course  of  the  optic  canal 
may  for  a  greater  or  less  distance  lie  actually  within  the  sphenoidal  sinus, 
or  the  ethmoidal  cell,  or  it  may  lie  in  close  proximity,  with  but  a 
thin  bone  intervening  between  the  nerve  and  the  sinus  cavity.  The 
ethmoidal  veins,  too,  not  infrequently  lie  exposed  in  the  semicanalis 
ethmoidalis. 

^  Zitntralblatt  für  Laryngologie,  Bd.  XXII. 

-  Archiv  für  Laryngologie,  Bd.  XVIII. 

^  Fuchs,  "  Lehrbuch  der  Augenheilkunde,"  1905. 

*  Lac.  cit.  ^  Orvosi  Hetilap.  ^  Ibid. 

"^    Verhandlungen  der  Deutschen  Olologischen  Gesellschaft,  1905. 

^  Archiv  für  Laryngologie,  Bd.  XVIII. 

^  La  Presse  Oto-Laryngologique  Beige,  1906. 


90  THE  OPTIC  XERVE 

That  contralateral  and  double  optic  disturbances  may  arise  from  a 
one-sided  disease  of  the  accessor}^  sinuses  is  to  be  explained  bv  the 
anatomical  conditions  that  may  exist,  and  that  have  already  been 
described.  According  to  my  observations,  the  following  anatomical 
relationships  are  possible  : 

1.  The  left  most  posterior  ethmoidal  cell  forms  the  inner  or  medial 
wall  of  the  right  optic  canal. 

2.  The  right  most  posterior  ethmoidal  cell  forms  the  floor  and  inner 
wall  of  the  optic  canal  on  both  sides,  and  the  wall  of  the  whole  optic 
sulcus. 

3.  The  right  most  posterior  ethmoidal  cell  forms  the  wall  of  the 
whole  optic  sulcus. 

4.  The  right  most  posterior  ethmoidal  cell  forms  the  wall  of  the 
right  third  and  the  middle  third  of  the  optic  sulcus. 

5.  The  left  sphenoidal  sinus  forms  the  floor  of  the  right  optic 
canal . 

6.  The  right  sphenoidal  sinus  is  onlv  in  relation  with  the  left  optic 
nerve  on  the  inner  or  medial  side. 

7.  The  left  sphenoidal  sinus  forms  the  floor  of  the  right  optic  canal, 
and  the  wall  of  the  right  and  middle  third  of  the  optic  sulcus. 

8.  The  left  sphenoidal  sinus  forms  the  floor  and  inner  walls  of  the 
optic  canals  on  both  sides,  and  the  wall  of  the  whole  optic  sulcus. 

9.  In  this  the  relations  are  similar  to  those  in  No.  8,  except  that  in 
addition  the  greater  part  of  the  floor  and  inner  wall  of  the  right 
optic  canal  is  formed  by  the  right  most  posterior  ethmoidal  cell. 

10.  The  left  sphenoidal  sinus  forms  the  floor  and  inner  wall  of  the 
left  optic  canal,  the  floor  of  the  right  optic  canal,  and  the  wall  of  the 
whole  optic  sulcus. 

11.  The  right  sphenoidal  sinus  forms  the  wall  of  the  middle  third 
of  the  optic  sulcus. 

The  presence  of  symptoms  of  unilateral  visual  disturbance  on  the 
side  opposite  to  that  of  the  disease  or  lesion  has  been  recorded  in  but 
few  cases.  Wohlmuth^  reports  a  case  of  traumatic  blindness  in  the  left 
eye,  with  signs  of  injury  visible  only  on  the  right  side  of  the  forehead 
over  the  right  orbital  ridge,  and  also  over  the  occiput  where  there 
was  a  horizontal  wound.  Berlin^  assumes  that  a  fracture  in  the  right 
orbital  roof  crossed  over  into  the  left  optic  canal,  or  that  the  fracture 
was  an  indirect  one  due  to  the  blow  on  the  occiput.     Freudenthal^ 

^  Berlin,  "  Graefe-Samisch,"  i  Aufl.  -  Ibid. 

^  Archives  Internat.  Chauveanx  et  St.  Hilaire,  Paris,  1905. 


CUXICAL  COXSIDFRATrOXS  qi 

saw  blindness  on  the  lelt  side,  witli  olnious  i>ptic  atrophy  six  weeks 
later,  due  to  an  operation  by  Killian's  niotluxi  on  the  right  frontal 
sinus.  The  ophthalmic  siiip^ons  OpixMiheinier  and  May  take  the 
view  that  in  consequence  of  the  ojxration  an  indirect  fracture  in  the 
region  of  the  left  optic  canal  txcnrrcd.  Freudenthal  accepted  this 
explanation,  as  no  other  seemed  probable, 

Laas  and  Lewy  report  a  case  in  which  a  septal  resection  was  carried 
out  from  the  left  nostril,  and  an  abrupt  spur  4  centimetres  long  and 
2i  centimetres  broad,  that  p;issed  backwards  and  upwards,  was 
removed.  A  quarter  of  an  hour  later  there  was  a  flickering  sensation 
in  the  right  eye,  \Wth  \-isual  defect.  Laas  found  a  complete  defect  in 
the  upper  half  of  the  \isual  field  in  the  right  eye.  The  fundus 
appeared  normal,  except  for  some  pallor  of  the  right  disc.  At  the 
end  of  two  weeks  the  optic  disc  showed  complete  pallor.  My  opinion 
being  asked  in  this  case,  I  said  I  thought  it  was  probabh'  a  fracture 
of  the  right  optic  canal.  Witli  this  view  Laas^  and  Lewy  agree.  The 
suddenness  of  the  onset  is  in  favour  of  it. 

It  has  been  shown  that  the  optic  canal  may  run  within  the 
sphenoidal  and  ethmoidal  sinuses ;  and  also  that  the  sphenoidal  sinus 
may  extend  between  the  lamellae  of  the  nasal  septum  at  its  posterior 
attachment  to  the  sphenoid.  Further,  the  ethmoidal  or  sphenoidal 
sinus  of  one  side  may  cross  over  the  middle  line.  These  facts,  illus- 
trated in  Figures  14.  15,  67,  yz,  73  (Atlas),  will  give  an  anatomical 
basis  for  the  explanation  of  such  a  fracture. 

Even  though  a  fracture  of  the  optic  canal  on  the  same  side  is  more 
frequently  observed,  the  cases  just  mentioned  ma\'  quite  possiblv  be 
explained  by  the  CKrcurrence  of  an  indirect  fracture.  It  mav  happen 
that  an  optic  canal  is  separated  by  a  ver\-  thin  plate  of  bone  from  the 
sphenoidal  sinus  or  posterior  ethmoidal  cell  of  the  side  opposite  to 
that  on  which  the  sinuses  are  affected. 

In  explaining  these  cases  b\-  a  fracture  of  the  optic  canal,  it  must 
necessarily  be  assumed  that  it  is  an  indirect  fracture.  Holder  found 
fracture  of  the  optic  canal  in  fiftv-three  cases.  Freudenthal 's  case, 
if  correctly  explained,  is  a  unique  one.  It  must  have  occurred  on 
removal  of  the  floor  of  the  frontal  sinus,  as,  in  his  patient,  a  Kuhnt 
operation  had  already  been  done  on  some  pre\äous  occasion. 

Neither  a  traumatic  fracture  on  the  same  side,  nor  on  the  opposite 
side,  invohing  the  optic  nerve,  has  vet  been  observed  in  any  other  of 

^  Laas  reported  the  case  durmg  the  February-  session  of  the  Berliner  Ophthalmo- 
logischen Gesellschaft. 


92  THE  OPTIC  XERVE 

the  numerous  cases  of  frontal  sinus  operation  b}^  Killian's  method.  Yet 
in  the  ordinary  cases  of  Killian's  operation  the  hammer  and  chisel  are 
more  freely  used  than  in  Freudenthal 's  already  partially  completed 
operation.  Halstead^  reported  a  case  of  right,  maxillary,  ethmoidal, 
and  sphenoidal  suppuration  in  which  blindness  of  the  left  eye  occurred. 
Halstead  assumed  that  the  left  sphenoidal  sinus  was  opened  into 
by  the  disease,  and  that  secondarily  to  this  a  left  optic  neuritis 
occurred.  He  then  operated.  As  six  months  after  the  operation 
the  e3^e  was  again  normal,  Brown  assumes  that  an  exudate  had  occurred 
into  the  sheath  of  the  optic  nerve.  The  ethmoidal  cells  might  just  as 
well  have  been  responsible,  and  even  in  spreading  the  inflammation 
to  the  opposite  side  the  ethmoidal  cells  may  be  just  as  active  as  the 
sphenoidal  sinus. 

Halstead's  theory  that  it  was  due  to  a  rupture  into  the  left 
sphenoidal  sinus  is  an  unnecessary  hypothesis.  Glegg  and  Hay  ^  reported 
a  case  of  bitemporal  hemianopsia  and  paralysis  of  association  move- 
ments due  to  ethmoidal  suppuration  on  the  right  side.  They  assume 
the  lesion  to  be  one  of  the  optic  chiasma,  and  of  Gudden's  commissure, 
thus  accounting  for  paralysis  of  association  movements.  Cure  of 
the  eye  lesion  occurred  after  operating  on  the  disease.  In  this  case 
the  ethmoidal  cells  may  just  as  easily  have  been  the  cause  of  the 
chiasma  lesion  as  disease  of  the  sphenoidal  sinus.  Pollatschek^  had 
a  case  of  ethmoidal  and  sphenoidal  suppuration  on  the  left  side  in 
which  double  optic  neuritis  was  present.  After  operative  treatment 
cure  of  the  neuritis  occurred.  In  explanation,  he  assumes  the  exist- 
ence of  a  dehiscence  in  the  wall  of  one  or  both  sphenoidal  sinuses,  and  an 
extension  by  periostitis  to  both  optic  nerves.  This  he  thinks  most 
probable.  Much  stinking  pus  came  from  the  posterior  ethmoidal 
cells,  and  but  little  pus  from  the  sphenoidal  sinus.  He  gives  no  par- 
ticulars as  to  the  amount  of  expansion  of  either  the  posterior  ethmoidal 
cells  or  of  the  sphenoidal  sinus,  nor  does  he  assign  any  reason  for 
excluding  as  a  factor  in  the  causation  of  the  optic  neuritis  the  disease  in 
the  posterior  ethmoidal  cells.  The  ethmoidal  cells  may  be  an  important 
factor  in  such  affections  of  the  optic  nerves.  We  must,  however,  bear 
in  mind  the  possibility  of  an  accidental  association  of  the  optic  neuritis 
with  the  diseased  sinuses. 

Polyak"*  reports  a  case  of  exophthalmos  and  optic  atrophy  on  both 

^  American  Laryng.,  Rhin,,  and  Otol.  Society,  1901. 

^  Archiv  für  Laryngologie,  Bd.  XVII. 

^  Zentralblatt  für  Laryngologie,  Bd.  XXII. 

*  Archiv  für  Laryngologie,  Bd.  XV. 


CLINICAL  CONSIDERATIONS  93 

sides,  in  which  the  right  eye  became  affected  a  year  before  the  left. 
Bullous  air-cells  were  present  on  the  left  side,  with  multiple  latent 
accessory  sinus  empyemata.  He  assumes  that  the  pus  in  the  left 
bullous  cells  tracked  to  the  sinuses  of  the  left  side,  and  then  to  those 
of  the  right.  Finding  no  exit,  it  caused  dilatation  of  the  sinuses,  and 
so  pressure  effects.  Thus  both  the  exophthalmos  and  the  optic  atrophy 
can  be  explained.  Polyak's  explanation  I  held  was  not  tenable. 
Both  Goldzieher  and  I  propounded  an  explanation,  but  this  it  is 
needless  to  state  now,  as  the  condition  will  probably  soon  be  cleared 
up  by  an  autopsy.  Gutmann^  observed  a  case  of  blindness  in  the 
right  eye  that  developed  in  association  with  suppuration  of  the 
left  maxillary  antrum.  He  believes  that  the  disease  extended  to  the 
ethmoidal  and  sphenoidal  sinuses,  and  so  crossed  to  the  opposite  side 
and  involved  the  optic  nerve,  causing  amaurosis.  In  my  own  case  a 
suppuration  of  the  posterior  ethmoidal  cells,  and  of  the  sphenoidal 
sinus,  was  associated  with  optic  atrophy  of  long  standing  on  the  right 
side,  and  optic  neuritis  with  temporal  hemianopsia  on  the  left  side. 
The  left  eye  improved  slightly  after  operation,  from  {'-  to  yj.  Six  years 
previously  many  polypi  had  been  removed  from  the  left  nasal  cavity. 
This  was  followed  by  purulent  discharge  of  offensive  odour  on  that 
side.  There  was  continual  headache  ;  in  two  months'  time  the  right 
eye  became  blind,  and  three  months  later  the  visual  disturbance  in  the 
left  e3'e  commenced.  When  examined,  the  left  eye  showed  temporal 
hemianopsia.  There  was  no  history  of  syphilis,  and  treatment  bv 
mercury  and  iodides  had  no  effect. 

In  Figure  50  a  diagram  of  the  defect  in  the  visual  field  is 
shown.  The  patient,  recommended  to  me  by  Professor  Szily,  passed 
out  of  further  observation,  and  her  subsequent  history  is  unknown 
to  me.  We  agreed  that  there  was  a  true  ^etiological  connection  between 
the  accessory  sinus  disease  and  the  visual  disturbance.  I  have  a 
specimen  in  which  the  left  sphenoidal  sinus  bounds  only  the  right 
optic  canal  and  the  middle  third  of  the  optic  sulcus.  In  such  a 
relation,  a  lesion  of  the  right  optic  nerve  and  chiasma,  leading  to 
atrophy  of  the  right  nerve,  and  producing  hemianopsia  on  the  left 
side,  might  possibly  be  induced  by  sphenoidal  sinus  disease.  An 
accidental  association  of  the  optic  trouble  with  the  sinus  disease  is  also 
possible,  but  this  could  only  be  decided  by  post-mortem  examination. 

As  regards  the  deductions  from  anatomical  data  which  indicate 
the  possibility  of  visual  disturbance  on  the  opposite  side  from  sinus 
^  Zeitschrift  f.ir  Augenheilkunde,  1906. 


94 


THE  OPTIC  XERVE 


disease,  or  the  occurrence  of  double  optic  neuritis  from  unilateral 
nasal  disease,  it  must  be  acknowledged  that  they  are  as  yet  uncon- 
firmed by  post-mortem  evidence. 

The  treatment  of  the  individual  sinuses  is  dealt  with  in  detail 
in  my  book  on  that  subject  ;^  I  will  only  now  emphasize  this  one  point. 
In  cases  of  visual  disturbance  in  which  the  ophthalmic  surgeon  can 
come  to  no  conclusion,  and  in  which  accessory  sinus  disease  is  a  possible 
factor,  the  rhinologist  should  not  rest  content  until  he  has  proved  that 
there  is  no  latent  suppuration.    Even  should  it  appear,  on  exploration. 


that  there  is  no  latent  suppuration,  this  knowledge  is  yet  of  service 
in  excluding  accessory  sinus  disease.  Schmiegelow's-  interesting  case, 
and  the  favourable  results  that  followed,  confirm  this  view. 

In  closing  these  observations  on  an  interesting  subject,  we  may  take 
it  as  firmlv  established  that  accessory  sinus  disease,  both  ethmoidal 
and  sphenoidal,  may  cause  visual  disturbance  or  blindness  on  one 
or  both  sides,  or  disease  of  the  optic  nerve  of  the  opposite  side.     And 

^  Önodi  and  Rosenberg,  "  Die  Behandlung  der  Krankheiten  der  Xase  und  des 
Xasen-Rachcnraunies,"  1906. 
^  Loc.  cit. 


CLINICAL  CONSIDERATIONS 


95 


though  our  pathological  knowledge  is  not  complete,  the  anatomical 
relations  that  may  be  present  suffice  to  explain  every  clinical 
finding.  Improbable  hypotheses  need  thus  no  longer  be  put  forward 
to  explain  all  the  associated  symptoms  and  complications  of  accessory 
sinus  suppuration.  Careful  clinical  observations,  both  by  ophthal- 
mologists and  rhinologists,  and,  where  possible,  post-mortem  examina- 
tions, will  in  time  fully  develop  our  knowledge  of  this  important 
subject. 

In  addition  to  the  visual  disturbances  already  dwelt  on,  we  have 
to  consider  another  defect  that  has  recently  been  receiving  attention. 
Fuchs's  observations  lead  him  to  think  that  acute  retrobulbar  neuritis 
with  central  scotoma  frequently  occurs  after  nasal  catarrh  and  influ- 
enza. Rhinological  examination  may  be  negative.  The  central 
scotoma  is  due  to  affection  of  the  papillo-macular  bundle  of  the  optic 
nerve,  which  runs  axially.  Hyperaemia  and  swelling  of  the  nerve 
sheath  induces  this  change  in  the  axial  nerve  bundle,  which  seems 
peculiarly  vulnerable.  That  it  is  not  destroyed  in  structure  is  certain, 
because  of  the  frequent  restoration  to  normal  function  that  occurs. 

Accessory  sinus  suppuration  and  pressure  on  the  nerve,  or  on  the 
bloodvessels  of  that  part  which  receives  recurrent  twigs  from  the 
central  artery  of  the  retina,  and  which  the  central  vein  of  the  retina 
joins,  may  cause  a  similar  condition  of  central  scotoma.  Swelling 
within  that  part  of  the  optic  canal  may  cause  venous  congestion,  and 
so  injure  the  papillo-macular  bundle.  A  venous  congestion  within 
the  accessory  sinuses  and  nasal  cavities  may  likewise  indirectly  affect 
the  optic  nerve.  The  veins  in  the  semicanalis  ethmoidalis,  as  has 
already  been  described,  may  run  exposed  in  some  of  the  ethmoidal 
cells,  and  so  be  open  to  pressure  and  infection.  Zuckerkandl  has 
described  a  venous  twig  that  may  run  exposed  in  some  ethmoidal 
cells.  And,  as  has  been  described,  the  optic  nerve  may  be  in  close 
relation  to  the  sphenoidal  sinus  and  posterior  ethmoidal  cell  ;  the 
optic  canal  may  even  lie  within  the  cavities. 

That  inflammations  in  the  sinuses,  by  direct  extensicju  to  the  nerve 
sheath  or  through  veins,  may  cause  a  disturbance  of  the  axial  bundle 
of  the  optic  nerve  is  easily  comprehensible.  Toxic  effects,  too,  may 
produce  the  central  scotoma.  It  is  through  its  vulnerabilitv  to  toxins 
that  the  lesions  of  the  papillo-macular  bundle  are  best  known.  This 
explains  tobacco  amblyopia.  Birsch-Hirschfeld  lays  emphasis  on  this 
vulnerability.     Experimentally  and  clinicallv  this  axial  degeneration 


g6  THE  OPTIC  XERVE 

has  been  proved.  He  believes  that  the  presence  of  a  central  scotoma 
is  an  early  and  important  symptom  of  suppuration  in  the  posterior 
accessory  sinuses,  or  of  the  presence  of  a  tumour  there.  In  a  case  of 
carcinoma  with  this  symptom,  he  was  able  to  point  out  an  isolated 
axial  degeneration  of  the  optic  nerve  posterior  to  the  point  of  entry 
into  the  nerve  of  the  vena  centralis  retinae.  The  new  growth  pressed 
on  the  central  vein  and  caused  axial  degeneration,  as  well  as  separation 
through  oedema  of  the  neuroglia  fibres  and  septal  sheaths,  and  increase 
as  well  as  turbiditv  of  the  neuroglia  cells.  This  he  ascribes  to  venous 
congestion  and  toxic  oedema  caused  by  compression  of  the  central 
retinal  vein  by  the  tumour.  As  the  periphery  of  the  visual  field  was 
normal,  the  phenomena  cannot  be  ascribed  to  direct  pressure. 
We  must  assume  that  the  axial  degeneration  was  due  to  a 
toxin. 

In  a  case  of  mine  in  which  I  did  not  test  for  scotoma,  the  optic 
nerve  was  histologically  normal.  Yet  the  nerve  in  its  optic  canal 
was  surrounded  by  sarcoma.  In  this  case  the  microscopic  examina- 
tion showed  distinct  pressure  on,  and  congestion  of,  the  central  vein 
of  the  retina.  The  fundus  of  the  eye  was  normal  in  appearance  as 
seen  by  the  ophthalmoscope.  It  is  legitimate  therefore  to  assume  that 
accessory  sinus  suppuration  may  cause  central  scotoma  in  the  visual 
field,  in  the  same  way  as  it  occurred  in  Birsch-Hirschfeld's  case. 
Birsch-Hirschfeld  thinks  that  a  one-sided  visual  disturbance  is 
characteristic  of  accessory  sinus  suppuration,  as  contrasted  with 
double  optic  neuritis  of  toxic  origin,  or  such  as  are  caused  by  general 
infections. 

Complications  not  sufficiently  referred  to  in  describing  ocular 
disturbances  in  accessory  sinus  suppuration  are  neuritis  of  the  fifth 
nerve  and  paresis  of  the  motor  nerves  of  the  eye  muscles.  Thomson 
observed  complete  oculo-motor  paralysis  in  a  case  of  suppuration  of 
the  ethmoidal  and  sphenoidal  sinuses. 

Hoffmann,  Lapersonne,  and  Stanculeanu,  observed  oculo-motor 
paralysis  in  cases  of  sphenoidal  sinus  suppuration.  Baumgarten  has 
seen  oculo-motor  paralysis  in  accessory  sinus  suppuration,  and  Panas 
paralysis  of  the  abducens  and  also  of  the  fifth  nerve.  Mahu  describes 
abducens  paralysis,  and  Fisch  paralysis  of  the  adducens  and  abducens. 
Panas  has  seen  anaesthesia  of  the  second  division  of  the  fifth  nerve  ; 
Rouge,  infra-orbital  neuralgia ;  and  Schäfer,  Moreau,  Hajek,  and 
Schröder,  supra-orbital  neuralgia.  In  some  cases  the  anatomical 
relations  of  the  accessory  sinuses  render  such  complications  possible. 


CLINICAL  CONSIDERATIONS  97 

The  sphenoidal  sinuses  and  the  posterior  ethmoidal  cells  may  extend 
into  the  large  and  small  wings  of  the  sphenoid  ;  the  whole  of  the  sella 
turcica  may  rest  upon  the  sphenoidal  sinus,  and  its  anterior  half  may 
even  lie  over  the  most  posterior  ethmoidal  cell.  The  sphenoidal  sinuses 
and  ethmoidal  cells  may  border  on  both  the  foramen  rotundum  and 
foramen  ovale.  And  as  these  sinuses  may  come  into  close  relation 
with  the  structures  that  pass  through  the  sphenoidal  fissure,  it 
seems  a  feasible  explanation  that  disease  of  the  bone  walls  of  the 
sphenoidal  sinuses  and  ethmoidal  cells,  as  well  as  cavernous  sinus 
thrombosis,  may  affect  branches  of  the  fifth  nerve,  as  well  as  the 
motor  nerves  that  go  to  the  ocular  muscles.  Intracranial  suppuration 
may  also  cause  paresis  of  these  motor  nerves.  Tumours  are  a  frequent 
cause  of  oculo-motor  paralysis.  Excluding  cases  due  to  cavernous  sinus 
thrombosis  and  intracranial  suppuration,  these  nerve  lesions  are  of 
comparatively  rare  occurrence  in  connection  with  accessory  sinus 
suppuration.  This  comparative  rarity  is  to  be  explained  by  the 
thickness  of  the  sphenoidal  walls,  even  when  the  cavity  is  exceptionally 
expanded. 

The  symptoms  of  asthenopia  in  ethmoidal  suppuration  have  already 
been  referred  to.  Moreau  and  Schröder  have  described  accommoda- 
tive asthenopia  in  cases  of  sphenoidal  sinus  suppuration.  Lapersonne 
and  Fisch  have  also  reported  cases  in  which  intra-ocular  tension  was 
raised  in  consequence  of  accessory  sinus  suppuration. 

Before  passing  on  to  consider  briefly  some  points  in  the  diagnosis  of 
cases  of  visual  disturbance  produced  through  accessory  sinus  suppura- 
tion, it  may  be  mentioned  that  traumatic  lesions  have  occasionally 
been  induced  in  the  form  of  paraffin  emboli.  In  treating  saddle  de- 
pressions of  the  nose  by  subcutaneous  injection  of  warm  liquid 
paraffin,  and  in  the  submucous  injection  of  the  same  material  in  cases 
of  ozsena,  various  authors  have  reported  phlebitis,  thrombosis,  and 
emboli,  and  a  condition  of  "  paraffinome  "  in  the  eyelids.  In  a  few 
cases  thrombosis  of  the  ophthalmic  vein  and  embolism  of  the  central 
artery  of  the  retina  have  been  recorded.  These  complications  are 
avoided  by  using  cold,  sterile  paraffin  with  a  melting-point  higher  than 
the  blood  temperature,  or  even  a  fever  temperature. 

As  regards  the  clinical  diagnosis  of  a  case  of  visual  disturbance 
that  may  be  associated  with  accessory  sinus  disease,  two  facts  must  be 
borne  in  mind.  The  fundus  of  an  eye  may  appear  normal,  and  yet  a 
serious  visual  defect  be  present,  or  the  field  of  vision  be  altered  and 
scotomata  be  present.     Again,  the  nasal  cavities  may  appear  normal 

6 


98  THE  OPTIC  XERVE 

or  but  slighth'  altered  in  appearance  while  suppuration  is  nevertheless 
present  in  one  or  more  sinuses.  Also,  notwithstanding  good  \'ision, 
hyperaemia  and  some  swelling  of  the  optic  disc  may  be  present. 

And  as  accessory-  sinus  suppuration  in  cases  of  visual  disturbance 
may  be  an  accidental  coincidence,  it  is  evident  that  only  bv  careful 
investigation  can  a  diagnosis  be  made,  or  even  the  symptoms  present 
be  brought  to  light.  In  some  cases  it  is  impossible  clinicallv  to 
diagnose  as  to  the  causal  relationship  between  accessory  sinus  sup- 
puration and  \-isual  disturbance.  The  kind  of  \-isual  disturbance  in 
such  cases  varies  ;  the  ophthalmoscopic  picture,  too,  varies.  At  first, 
notwithstanding  complete  blindness,  as  in  cases  of  fracture  of  the  optic 
canal,  there  may  be  no  change  in  the  fundus.  Optic  atrophv  onlv 
appears  later. 

In  some  cases  of  suppuration  of  the  accessory  sinuses,  venous  con- 
gestion, slight  swelling,  and  blurred  edges,  are  seen  in  the  optic  discs. 
The  arteries,  too,  of  the  retina  mav  be  narrowed  and  the  veins  dilated. 
In  a  few  cases  a  typical  choked  disc  is  present.  True  optic  neuritis 
is  not  infrequent. 

In  a  few  cases  unilateral  and  bilateral  hemianopsia  has  been 
described  ;  also  a  central,  true  or  relative,  scotoma. 

In  addition  to  the  difhculty  sometimes  present,  of  discriminating 
whether  in  associated  nasal  disease  and  \'isual  disturbance  the  nasal 
disease  is  the  cause  of  an  optic  lesion,  we  have  yet  the  other  possibilit}- 
to  bear  in  mind — namelv.  that  an  optic  lesion  mav  be  due  to  accessor}' 
sinus  disease,  and  yet  the  accessory- sinus  disease  produce  no  visible  intra- 
nasal suppuration.  Such  latent  empyemata  can  only  be  revealed  by 
operative  exploration.  This  we  are  justified  in  undertaking  in  those 
cases  in  which  the  ophthalmic  surgeon  finds  svmptoms  pointing  to  a 
possible  cause  in  the  accessor}-  sinuses.  Thus  there  may  be  symptoms 
of  a  relative  or  absolute  central  scotoma,  a  varying  degree  of  failing 
visual  acuity,  contraction  of  the  \asual  field,  or  amaurosis.  In  such  a 
case  we  may  venture  on  exploring  the  posterior  accessory  sinuses,  as 
cures  have  been  reported  in  cases  of  this  nature  where  latent 
suppuration  was  discovered.  Disease  of  the  sphenoidal  sinuses  is  not 
uncommon  ;  more  rare  is  disease  of  the  posterior  ethmoidal  cells 
alone  ;  commoner  than  either  is  disease  of  both  posterior  ethmoidal 
cells  and  sphenoidal  sinuses.  In  exploration,  therefore,  it  is  necessar}- 
to  open  up  on  the  suspected  side,  intranasally,  both  the  posterior 
ethmoidal  cells  and  the  sphenoidal  sinus. 

The  association  of  optic  disturbances  with  tumour  growth  in  the 


CLINICAL  CONSIDERATIONS  99 

naso-pharynx  is  uncommon,  but  it  does  occur.  Through  communica- 
tions of  bloodvessels  and  of  lymph  channels  the  intracranial  cavity 
may  become  infected. 

A  direct  extension  of  a  tumour  on  to  the  optic  chiasma  and  motor 
nerves  of  the  eye  muscles  has  occurred  in  some  cases.  Not  infre- 
quently suppuration  of  the  posterior  accessory  sinuses  is  found  asso- 
ciated with  a  neoplasm.  Orbital  infections  may  occur  secondarily 
to  accessory  sinus  suppuration. 

Birsch-Hirschfeld  has  laid  emphasis  on  the  early  symptom  of  a 
central  scotoma  as  characteristic  of  a  tumour  in  the  neighbourhood 
of  the  posterior  accessory  sinuses.  This  he  ascribes  to  degeneration 
of  the  papillo-macular  bundle  of  the  optic  nerve,  caused  by  the  toxic 
effects  of  venous  congestion. 

Berger,  on  the  other  hand,  gives  as  characteristic  symptoms  of 
a  tumour  of  the  sphenoidal  sinus,  a  narrowing  of  the  visual  field, 
first  on  the  temporal  side,  then  concentrically,  and  finally  involving  the 
macula. 

Bull,  also,  on  finding  a  tumour  in  the  nose,  and  associated  with  it 
blindness  on  the  temporal  side  of  the  field,  with  intact  central  vision, 
diagnoses  the  site  of  the  tumour  as  in  the  sphenoidal  sinus.  Schmidt- 
Rimpler  had  a  case  in  which  both  optic  nerves  were  intact  notwith- 
standing the  infiltration  of  the  whole  body  of  the  sphenoid  with 
sarcoma.  I  have  cited  a  case  of  mine  on  a  par  with  this  case.  In 
Schmidt-Rimpler's  case,  however,  the  third,  fourth,  and  sixth  nerves 
were  partially  interrupted  in  their  function. 

Although  intracranial  tumours  as  well  as  intracranial  suppurations 
are  common  causes  of  "  choked  disc,"  yet  such  intracranial  complica- 
tions may  be  present  without  causing  a  change  in  the  appearance  of 
the  optic  discs. 

In  conclusion  I  wish  to  point  out  some  of  the  methods  of  treatment. 

Although  cures  of  optic  neuritis  and  of  oculo-motor  paresis 
have  been  recorded  in  cases  in  which  only  conservative  treatment 
was  carried  out,  yet  in  most  cases  of  disease  of  the  accessory  sinuses 
associated  with  visual  disturbance  a  free  opening  up  of  the  affected 
sinuses  is  indicated. 

As  the  importance  of  various  anatomical  variations  cannot  be  kept 
in  mind  too  carefully,  it  may  be  well  to  give  a  resume  of  such  variations. 

There  are  no  fewer  than  nine  procedures  that  may  be  required  in 
opening  up  the  anterior  wall  of  the  sphenoidal  sinus.  In  this  opera- 
tion the  opening  up  of  the  anterior  wall  of  the  sphenoidal  sinus  goes 

6—2 


100  THE  OPTIC  XERVE 

hand  in  hand  with  the  opening  up  of  the  posterior  ethmoidal  cells, 
except  in  cases  where  the  ethmoidal  cells  are  placed  in  series  above  the 
sphenoidal  sinus.  The  anterior  sphenoidal  wall,  for  operative  purposes, 
has  two  surfaces,  a  free  nasal  surface,  and  one  covered  by  the 
ethmoidal  cells.  Hajek  found  a  variation  in  the  breadth  of  this  entire 
wall  of  from  lo  to  i8  millimetres,  the  nasal  part  ranging  between  2-5 
and  7  millimetres,  and  the  ethmoidal  part  between  6  and  10  milli- 
metres. In  measurements  made  by  me.  the  extreme  variation  in  the 
breadth  of  the  whole  wall  ranged  between  8  and  28  millimetres,  the 
nasal  part  2  to  14  millimetres,  and  the  ethmoidal  part  i  to  18  milli- 
metres. 

A  direct  operative  procedure  for  opening  up  the  anterior  nasal 
wall  of  the  sphenoidal  sinus  is  possible  under  favourable  circumstances. 
In  other  cases,  the  procedure  to  adopt  when  suspecting  a  latent 
suppuration  is  to  remove  the  middle  turbinate,  lay  free  the  anterior 
sphenoidal  w'all,  and  open  up  the  posterior  ethmoidal  cells.  When 
visual  disturbances  are  caused  by  accessorv  sinus  disease,  the  sphenoidal 
sinuses  and  ethmoidal  cells  may  be  equally  responsible.  Hence  it 
is  wise  to  open  up  both  the  posterior  ethmoidal  cells  and  the  sphenoidal 
sinus,  even  if  the  operation  be  only  exploratory  for  a  suspected  latent 
suppuration.  And  where  suppuration  is  ob\aousl3'  present,  treatment 
by  cleansing  with  lotions  without  operating  is  often  impossible.  Even 
in  those  cases  where  the  posterior  ethmoidal  cells  lie  above  the  sphe- 
noidal sinuses,  resection  of  the  middle  turbinate  exposes  the  field  of 
operation  and  enables  the  operator  to  "  take  his  bearings." 

In  curetting  or  clearing  out  the  contents  of  these  cavities,  particular 
caution  must  be  exercised  in  working  on  the  outer  and  upper  walls, 
for  the  optic  canal  may  have  a  wall  in  common  with  these  cavities,  or 
it  ma\'  even  run  within  their  boundaries. 

Both  the  sphenoidal  sinuses  and  the  posterior  ethmoidal  cells  may 
be  much  expanded.  The  most  posterior  ethmoidal  cell  may  extend  over 
the  middle  line  to  the  region  of  the  optic  nerve  of  the  opposite  side  ; 
passing  by  the  optic  canal,  it  may  expand  into  the  small  wing  of  the 
sphenoid,  and  ma}-  even  extend  up  to  the  orbital  ftssure  and  foramen 
rotundum.  The  sphenoidal  sinus,  too,  may  reach  the  optic  nerve  of  the 
other  side  ;  anteriorly  it  may  reach  up  to  the  maxillary  antrum  and 
ethmoidal  bulla,  and  have  a  wall  in  common  with  them.  It  may  also 
extend  into  the  nasal  septum  for  a  distance  of  15  millimetres  anterior 
to  the  ostium  of  the  sphenoid.  Further,  it  mav  extend  as  a  recess 
towards  the  pterygo-palatine  fossa  and  into  the  cli\'us. 


CLINICAL  CONSIDERATIONS  loi 

In  endeavouring  to  reach  growths,  cysts,  or  accumulations  of  pus, 
situated  intracranially,  various  routes  have  been  used.  It  may  be  of 
interest  to  mention  them. 

In  a  boy  of  eleven  years  of  age  vision  was  reduced  to  one- 
sixth,  and  there  was  suppuration  in  the  ethmoidal  and  sphenoidal 
sinuses  ;  Goris  opened  these  up  intranasally.  As  meningeal  symptoms 
now  appeared,  he  determined  to  open  into  the  middle  cranial  fossa. 
By  entering  through  the  orbital  cavitv  up  to  the  optic  foramen, 
and  removing  the  posterior  ethmoidal  cells  as  well  as  the  uppei 
and  lateral  wall  of  the  optic  foramen,  he  was  enabled  to  open  up  an 
accumulation  of  pus  under  the  optic  chiasma.  A  strip  of  gauze  was 
inserted  underneath  the  chiasma.  The  symptoms  previously  observed 
disappeared,  and  the  visual  power  was  uninjured.  But  on  the  fifth 
day  the  child  died  of  meningitis. 

Methods  of  reaching  the  region  of  the  sella  turcica  are  various. 
Luc,  as  the  result  of  anatomical  studies,  favours  the  route  through  the 
maxillary  and  sphenoidal  sinuses.  Braun  also  favours  the  intranasal 
route,  and  shows  that  the  sella  turcica  can  be  reached  when  the 
cavernous  sinus  has  been  raised  up  from  its  bed.  Horzky  reaches 
tumours  of  the  hypophysis  by  trephining  the  lateral  wall  of  the  skuU. 

Schloffer,  Eiseisberg,  and  Loewe,  reach  the  same  region  by  resecting 
the  root  of  the  nose,  and  so  exposing  the  sphenoidal  sinuses,  through 
which  they  enter.  Krause  reached  an  imbedded  bullet,  which  lay  in 
the  region  of  the  optic  chiasma,  bv  trephining  above  the  orbital 
cavity,  and  elevating  the  dura  from  the  anterior  cranial  fossa.  He 
recommends  this  route  as  favourable  for  removing  cysts  and  tumours. 
Borchardt  recommends  the  same  route,  only  he  proceeds  intradurally. 
With  reference  to  reaching  the  deep-lying  recesses  of  the  sphenoidal 
sinus,  Loewe  recommends  the  resection  and  turning  forward  of  the  root 
of  the  nose.  Such  operations  are  difficult  and  dangerous,  because  of 
the  region  and  its  important  anatomical  relations,  and  because  of  the 
risk  both  of  escape  of  cerebro-spinal  fluid  and  of  meningitis. 


THE    END 


BAII.LlfeRE     TINDALL   AND   COX,    8,    HENRIETTA   STREET     COVENT  GARDEN 


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